Healthcare Provider Details

I. General information

NPI: 1043570062
Provider Name (Legal Business Name): JENNY'S ASSISTED LIVING FACILITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4534 HAMPSHIRE RD
TAMPA FL
33634-7328
US

IV. Provider business mailing address

16116 TAMPA ST
LUTZ FL
33548-6125
US

V. Phone/Fax

Practice location:
  • Phone: 813-210-0982
  • Fax:
Mailing address:
  • Phone: 813-210-0982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL11889
License Number StateFL

VIII. Authorized Official

Name: JENNY M SEGARRA
Title or Position: VICE-PRESIDENT
Credential:
Phone: 813-210-0982