MEDICARE: GARDENS OF TIME 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	12263	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265784391
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GARDENS OF TIME LLC

Provider Business Mailing Address
First Line	:	4603 N SAINT VINCENT ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-6671
Country	:	US
Telephone Number	:	813-443-0343
Fax Number	:	813-443-0343

Provider Business Practice Location Address
First Line	:	4603 N SAINT VINCENT ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-6671
Country	:	US
Telephone Number	:	813-443-0343
Fax Number	:	813-443-0343

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MARTHA JULIA MEDINA RODRIGUEZ
Credential	:	MGR
Telephone Number	:	813-443-0343

Provider Enumeration Date	:	10/13/2012
Last Update Date	:	10/13/2012

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