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General NPI Number Information
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NPI Number | 1760479901
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Entity Type | Organization
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Legal Business Name | JOHN KNOX VILLAGE OF TAMPA BAY INC
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Dates
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Enumeration Date | 10/03/2005
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Last Update Date | 11/07/2014
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Provider Practice Location Address
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Address Line | 4100 E. FLETCHER AVE
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City | TAMPA
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State | FL
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Zip | 33613-4863
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Country | US
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Telephone | 813-632-2455
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Fax | 813-632-2388
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Provider Business Mailing Address
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Address Line | 4100 E. FLETCHER AVE
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City | TAMPA
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State | FL
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Zip | 33613-4863
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Country | US
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Telephone | 813-632-2455
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Fax | 813-632-2388
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. LISA VICARIO LYONS
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Credential | NHA, CPA
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Telephone | 813-632-2391
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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 | SNF1260095
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL4110
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License Number State | FL
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