Provider Demographics
NPI:1144226440
Name:SA-PG-JACKSONVILLE LLC
Entity Type:Organization
Organization Name:SA-PG-JACKSONVILLE LLC
Other - Org Name:PALM GARDEN OF JACKSONVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:PALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-390-4363
Mailing Address - Street 1:5725 SPRING PARK RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5955
Mailing Address - Country:US
Mailing Address - Phone:904-733-6954
Mailing Address - Fax:904-733-4877
Practice Address - Street 1:5725 SPRING PARK RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5955
Practice Address - Country:US
Practice Address - Phone:904-733-6954
Practice Address - Fax:904-733-4877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1406096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025727300Medicaid
FL025727300Medicaid