Provider Demographics
NPI:1124022603
Name:LTCSP PASADENA, LLC
Entity Type:Organization
Organization Name:LTCSP PASADENA, LLC
Other - Org Name:PASADENA MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:JAFFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-346-6454
Mailing Address - Street 1:1675 PALM BEACH LAKES BLVD
Mailing Address - Street 2:SUITE 900
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401
Mailing Address - Country:US
Mailing Address - Phone:561-801-7600
Mailing Address - Fax:414-268-4811
Practice Address - Street 1:1430 PASADENA AVE S
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707-3716
Practice Address - Country:US
Practice Address - Phone:727-347-1257
Practice Address - Fax:727-381-5407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF14320962314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL028189100Medicaid
FL028189100Medicaid