MEDICARE: PALM GARDEN OF CLEARWATER 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	1407096	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	:	1457786410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALM GARDEN OF CLEARWATER LLC

Provider Business Mailing Address
First Line	:	2033 MAIN ST
Second Line	:	SUITE 302
City	:	SARASOTA
State	:	FL
Zip	:	34237-6056
Country	:	US
Telephone Number	:	941-952-9411
Fax Number	:	941-952-9331

Provider Business Practice Location Address
First Line	:	3480 N MCMULLEN BOOTH RD
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33761-1421
Country	:	US
Telephone Number	:	727-786-6697
Fax Number	:	727-781-0516

Authorized Official
Title or Position	:	AUTHORIZED REPRESENTATIVE
Name	:	MORRIS H. MILLER
Credential	:
Telephone Number	:	941-952-9411

Provider Enumeration Date	:	09/10/2013
Last Update Date	:	12/04/2013

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