MEDICARE: GV PINELLAS PARK, 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	311500000X	Alzheimer Center (Dementia Center)	5487	FL
2	310400000X	Assisted Living Facility	5489	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	:	1700226883
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GV PINELLAS PARK, LLC

Provider Business Mailing Address
First Line	:	13770 58TH STREET NORTH
Second Line	:	SUITE 312
City	:	CLEARWATER
State	:	FL
Zip	:	33760
Country	:	US
Telephone Number	:	727-726-3980
Fax Number	:

Provider Business Practice Location Address
First Line	:	8980 49TH STREET NORTH
Second Line	:
City	:	PINELLAS PARK
State	:	FL
Zip	:	33782
Country	:	US
Telephone Number	:	727-546-4053
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. NIKI PLUMMER
Credential	:
Telephone Number	:	727-726-3980

Provider Enumeration Date	:	07/03/2013
Last Update Date	:	07/03/2013

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