Healthcare Provider Details

I. General information

NPI: 1295723591
Provider Name (Legal Business Name): SENIOR CARE GOLFVIEW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 10TH AVE N
ST PETERSBURG FL
33713-6528
US

IV. Provider business mailing address

3636 10TH AVE N
ST PETERSBURG FL
33713-6528
US

V. Phone/Fax

Practice location:
  • Phone: 727-323-3611
  • Fax: 727-327-5802
Mailing address:
  • Phone: 727-323-3611
  • Fax: 727-327-5802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF11770962
License Number StateFL

VIII. Authorized Official

Name: RAYMOND L TYLER JR.
Title or Position: EXECUTIVE VICE PRESIDENT AND COO
Credential:
Phone: 615-771-7575