MEDICARE: 3865 TAMPA ROAD 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	SNF 1591096	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	:	1487678132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	3865 TAMPA ROAD LLC

Provider Business Mailing Address
First Line	:	101 SUN AVE NE
Second Line	:	COMPLIANCE DEPARTMENT
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-4373
Country	:	US
Telephone Number	:	505-468-5604
Fax Number	:	505-468-4681

Provider Business Practice Location Address
First Line	:	3865 TAMPA RD
Second Line	:
City	:	OLDSMAR
State	:	FL
Zip	:	34677-3008
Country	:	US
Telephone Number	:	813-855-4661
Fax Number	:	813-854-2129

Authorized Official
Title or Position	:	VP AND ASST SECRETARY
Name	:	MICHAEL THEODORE BERG
Credential	:
Telephone Number	:	505-468-4742

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	03/23/2018

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