Provider Demographics
NPI:1265855936
Name:GARDENS OF TIME LLC
Entity Type:Organization
Organization Name:GARDENS OF TIME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:JULIA
Authorized Official - Last Name:MEDINA RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-505-5564
Mailing Address - Street 1:4603 N SAINT VINCENT ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-6671
Mailing Address - Country:US
Mailing Address - Phone:813-505-5564
Mailing Address - Fax:813-443-0343
Practice Address - Street 1:4603 N SAINT VINCENT ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-6671
Practice Address - Country:US
Practice Address - Phone:813-505-5564
Practice Address - Fax:813-443-0343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 12263261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006738700Medicaid