MEDICARE: SOVEREIGN HEALTHCARE OF PINELLAS POINT, 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	314000000X	Skilled Nursing Facility	SNF16060961	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V516P-6821	OTHER		VA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295722817
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOVEREIGN HEALTHCARE OF PINELLAS POINT, LLC

Provider Business Mailing Address
First Line	:	5887 GLENRIDGE DR
Second Line	:	SUITE 150
City	:	ATLANTA
State	:	GA
Zip	:	30328-5574
Country	:	US
Telephone Number	:	404-574-2100
Fax Number	:	404-574-2105

Provider Business Practice Location Address
First Line	:	5601 31ST ST S
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33712-4605
Country	:	US
Telephone Number	:	727-867-6955
Fax Number	:	727-867-1824

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. R. MARK CRONQUIST
Credential	:
Telephone Number	:	404-574-2100

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	09/24/2014

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