=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578569703
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SA-PG -SUN CITY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2005
-----------------------------------------------------
Last Update Date | 07/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3850 UPPER CREEK DR
-----------------------------------------------------
City | RUSKIN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33573-6813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-633-2875
-----------------------------------------------------
Fax | 813-633-8402
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3850 UPPER CREEK DR
-----------------------------------------------------
City | RUSKIN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33573-6813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-633-2875
-----------------------------------------------------
Fax | 813-633-8402
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | MR. ALEX PALEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 914-390-4363
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | SNF1421096
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------