1255763256 NPI number — EXTENDED CARE PORTFOLIO FLORIDA TENANT, LLC

Table of content: (NPI 1255763256)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255763256 NPI number — EXTENDED CARE PORTFOLIO FLORIDA TENANT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXTENDED CARE PORTFOLIO FLORIDA TENANT, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PACIFICA SENIOR LIVING CARPENTER'S CREEK
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255763256
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13770 58TH ST N
Provider Second Line Business Mailing Address:
SUITE 312
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33760-3759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-726-3980
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5918 N DAVIS HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32503-2050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-477-8998
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/01/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PLATTEN
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
850-477-8998

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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