Healthcare Provider Details

I. General information

NPI: 1053746008
Provider Name (Legal Business Name): PALM GARDEN OF TAMPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 12/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3612 E 138TH AVE
TAMPA FL
33613-4703
US

IV. Provider business mailing address

2033 MAIN ST SUITE 302
SARASOTA FL
34237-6056
US

V. Phone/Fax

Practice location:
  • Phone: 813-972-8775
  • Fax: 813-978-0680
Mailing address:
  • Phone: 941-952-9411
  • Fax: 941-952-9331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1420095
License Number StateFL

VIII. Authorized Official

Name: MORRIS H. MILLER
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 941-952-9411