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General NPI Number Information
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NPI Number | 1487678132
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Entity Type | Organization
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Legal Business Name | 3865 TAMPA ROAD LLC
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Dates
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Enumeration Date | 07/26/2006
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Last Update Date | 03/23/2018
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Provider Practice Location Address
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Address Line | 3865 TAMPA RD
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City | OLDSMAR
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State | FL
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Zip | 34677-3008
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Country | US
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Telephone | 813-855-4661
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Fax | 813-854-2129
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Provider Business Mailing Address
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Address Line | 101 SUN AVE NE COMPLIANCE DEPARTMENT
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City | ALBUQUERQUE
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State | NM
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Zip | 87109-4373
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Country | US
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Telephone | 505-468-5604
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Fax | 505-468-4681
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Authorized Official
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Title or Position | VP AND ASST SECRETARY
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Name | MICHAEL THEODORE BERG
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Credential |
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Telephone | 505-468-4742
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | SNF 1591096
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License Number State | FL
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