Healthcare Provider Details

I. General information

NPI: 1104419159
Provider Name (Legal Business Name): SUTHERLAND SNF OPERATOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2021
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 E 4TH ST
SUTHERLAND IA
51058-7668
US

IV. Provider business mailing address

15310 AMBERLY DR STE 102
TAMPA FL
33647-2145
US

V. Phone/Fax

Practice location:
  • Phone: 712-446-3857
  • Fax:
Mailing address:
  • Phone: 813-347-9453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. BRUCE WERTHEIM
Title or Position: SOLE MEMBER
Credential:
Phone: 813-347-9453