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General NPI Number Information
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NPI Number | 1861820540
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Entity Type | Organization
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Legal Business Name | GLADE GARDEN INC
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Dates
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Enumeration Date | 10/16/2013
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Last Update Date | 10/16/2013
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Provider Practice Location Address
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Address Line | 5860 91ST AVE N
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City | PINELLAS PARK
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State | FL
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Zip | 33782-4910
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Country | US
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Telephone | 727-258-4537
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Fax | 727-544-2716
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Provider Business Mailing Address
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Address Line | 5860 91ST AVE N
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City | PINELLAS PARK
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State | FL
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Zip | 33782-4910
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Country | US
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Telephone | 727-258-4537
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Fax | 727-544-2716
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | ENA REDZIC
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Credential |
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Telephone | 727-507-1934
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL12375
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License Number State | FL
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