Healthcare Provider Details

I. General information

NPI: 1548217060
Provider Name (Legal Business Name): MENORAH MANOR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2006
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 59TH ST N
ST PETERSBURG FL
33710
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 727-345-2775
  • Fax: 727-344-8593
Mailing address:
  • Phone: 727-345-2775
  • Fax: 727-344-8593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1344096
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4037350001
License Number StateFL

VIII. Authorized Official

Name: MRS. DONNA PERRYMAN
Title or Position: CHIEF FINANCIAL OFFICER
Credential: CPA
Phone: 727-302-3702