Healthcare Provider Details

I. General information

NPI: 1912330424
Provider Name (Legal Business Name): EXTENDED CARE PORTFOLIO TENANT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2013
Last Update Date: 08/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3207 N MONROE ST
TALLAHASSEE FL
32303-2832
US

IV. Provider business mailing address

13770 58TH ST N SUITE 312
CLEARWATER FL
33760-3759
US

V. Phone/Fax

Practice location:
  • Phone: 850-562-4123
  • Fax:
Mailing address:
  • Phone: 727-726-3980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL99
License Number StateFL

VIII. Authorized Official

Name: TERESA EDWARDS
Title or Position: MANAGER
Credential:
Phone: 727-726-3980