MEDICARE: PALM AVENUE BAPTIST TOWER, INC

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	310400000X	Assisted Living Facility	10783	FL

General Provider Information

NPI Number	:	1790048551
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALM AVENUE BAPTIST TOWER, INC

Provider Business Mailing Address
First Line	:	215 E PALM AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33602-2236
Country	:	US
Telephone Number	:	813-223-2686
Fax Number	:	813-223-6983

Provider Business Practice Location Address
First Line	:	215 E PALM AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33602-2236
Country	:	US
Telephone Number	:	813-223-2686
Fax Number	:	813-223-6983

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	LINA M ZULUAGA
Credential	:
Telephone Number	:	813-223-2686

Provider Enumeration Date	:	06/18/2012
Last Update Date	:	06/18/2012

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