Healthcare Provider Details

I. General information

NPI: 1265855936
Provider Name (Legal Business Name): GARDENS OF TIME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2014
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4603 N SAINT VINCENT ST
TAMPA FL
33614-6671
US

IV. Provider business mailing address

4603 N SAINT VINCENT ST
TAMPA FL
33614-6671
US

V. Phone/Fax

Practice location:
  • Phone: 813-505-5564
  • Fax: 813-443-0343
Mailing address:
  • Phone: 813-505-5564
  • Fax: 813-443-0343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberAL 12263
License Number StateFL

VIII. Authorized Official

Name: MARTHA JULIA MEDINA RODRIGUEZ
Title or Position: MANAGER
Credential:
Phone: 813-505-5564