MEDICARE: LTCSP ST. PETERSBURG, 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	SNF14800962	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	:	1740284223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LTCSP ST. PETERSBURG, LLC

Provider Business Mailing Address
First Line	:	1675 PALM BEACH LAKES BLVD
Second Line	:	SUITE 900
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401
Country	:	US
Telephone Number	:	561-801-7600
Fax Number	:	414-268-4811

Provider Business Practice Location Address
First Line	:	3479 54TH AVE N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33714-2426
Country	:	US
Telephone Number	:	727-527-7315
Fax Number	:	727-526-5887

Authorized Official
Title or Position	:	PRESIDENT
Name	:	HOWARD JAFFE
Credential	:
Telephone Number	:	215-346-6454

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	10/05/2012

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