Healthcare Provider Details

I. General information

NPI: 1972700169
Provider Name (Legal Business Name): JOHNNIE B BYRD SR ALZHEIMERS CENTER AND RESEARCH INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 E FLETCHER AVE
TAMPA FL
33613-4808
US

IV. Provider business mailing address

4001 E FLETCHER AVE
TAMPA FL
33613-4808
US

V. Phone/Fax

Practice location:
  • Phone: 813-866-1611
  • Fax: 813-866-1612
Mailing address:
  • Phone: 813-866-1611
  • Fax: 813-866-1612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberME31300
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW 7429
License Number StateFL

VIII. Authorized Official

Name: MS. LILLY HO - PEHLING
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 813-866-1610