Provider Demographics
NPI:1134125362
Name:SA-ST. PETERSBURG, LLC
Entity Type:Organization
Organization Name:SA-ST. PETERSBURG, LLC
Other - Org Name:PALM TERRACE OF ST. PETERSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WERTHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-390-4322
Mailing Address - Street 1:521 69TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-6810
Mailing Address - Country:US
Mailing Address - Phone:727-526-7000
Mailing Address - Fax:727-527-7270
Practice Address - Street 1:521 69TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-6810
Practice Address - Country:US
Practice Address - Phone:727-526-7000
Practice Address - Fax:727-527-7270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1240961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106033Medicare ID - Type UnspecifiedMEDICARE