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General NPI Number Information
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NPI Number | 1922401488
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Entity Type | Organization
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Legal Business Name | PATTY'S HOUSE 4 LLC
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Dates
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Enumeration Date | 09/29/2014
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Last Update Date | 09/29/2014
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Provider Practice Location Address
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Address Line | 2805 JERRY SMITH RD
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City | DOVER
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State | FL
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Zip | 33527-5449
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Country | US
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Telephone | 813-752-8034
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Fax |
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Provider Business Mailing Address
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Address Line | 2805 JERRY SMITH RD
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City | DOVER
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State | FL
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Zip | 33527-5449
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TONYA MAYO
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Credential |
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Telephone | 813-742-8034
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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 | AL12242
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License Number State | FL
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