MEDICARE: BAMBOO VILLAS ASSITED LIVING FACILITY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	11420	FL

General Provider Information

NPI Number	:	1114343837
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAMBOO VILLAS ASSITED LIVING FACILITY, LLC

Provider Business Mailing Address
First Line	:	2730 W WILDER AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-6809
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2730 W WILDER AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-6809
Country	:	US
Telephone Number	:	813-766-4018
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RODOLFO SUMULONG
Credential	:
Telephone Number	:	813-766-4018

Provider Enumeration Date	:	03/06/2014
Last Update Date	:	03/06/2014

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