MEDICARE: SENIOR CARE SOUTHERN PINES 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	SNF15060961	FL

General Provider Information

NPI Number	:	1346238631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SENIOR CARE SOUTHERN PINES LLC

Provider Business Mailing Address
First Line	:	6140 CONGRESS ST
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34653-3909
Country	:	US
Telephone Number	:	727-842-8402
Fax Number	:	727-841-8060

Provider Business Practice Location Address
First Line	:	6140 CONGRESS ST
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34653-3909
Country	:	US
Telephone Number	:	727-842-8402
Fax Number	:	727-841-8060

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT AND COO
Name	:	RAYMOND L TYLER JR.
Credential	:
Telephone Number	:	615-771-7575

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	11/09/2007

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