Provider Demographics
NPI:1073721718
Name:TYRONE MANOR
Entity Type:Organization
Organization Name:TYRONE MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:WING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-434-2115
Mailing Address - Street 1:2192 74TH ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-4635
Mailing Address - Country:US
Mailing Address - Phone:727-434-2115
Mailing Address - Fax:
Practice Address - Street 1:2192 74TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-4635
Practice Address - Country:US
Practice Address - Phone:727-434-2115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7309305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service