Healthcare Provider Details

I. General information

NPI: 1215394093
Provider Name (Legal Business Name): MENORAH MANOR, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 02/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 59TH ST N
ST PETERSBURG FL
33710-8539
US

IV. Provider business mailing address

255 59TH ST N
ST PETERSBURG FL
33710-8539
US

V. Phone/Fax

Practice location:
  • Phone: 727-302-3702
  • Fax: 727-345-3957
Mailing address:
  • Phone: 727-302-3702
  • Fax: 727-345-3957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number8869
License Number StateFL

VIII. Authorized Official

Name: MRS. DONNA PERRYMAN
Title or Position: CFO
Credential:
Phone: 727-302-3702