Provider Demographics
NPI:1053746008
Name:PALM GARDEN OF TAMPA LLC
Entity type:Organization
Organization Name:PALM GARDEN OF TAMPA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:MORRIS
Authorized Official - Middle Name:H
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-952-9411
Mailing Address - Street 1:2033 MAIN ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34237-6056
Mailing Address - Country:US
Mailing Address - Phone:941-952-9411
Mailing Address - Fax:941-952-9331
Practice Address - Street 1:3612 E 138TH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4703
Practice Address - Country:US
Practice Address - Phone:813-972-8775
Practice Address - Fax:813-978-0680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-10
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1420095314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105591Medicare Oscar/Certification