Provider Demographics
NPI:1285630954
Name:SA-PG TAMPA, LLC D/B/A PALM GARDEN OF TAMPA
Entity Type:Organization
Organization Name:SA-PG TAMPA, LLC D/B/A PALM GARDEN OF TAMPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:J
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:813-972-8775
Mailing Address - Street 1:3612 E 138TH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4703
Mailing Address - Country:US
Mailing Address - Phone:813-972-8775
Mailing Address - Fax:813-978-0680
Practice Address - Street 1:3612 E 138TH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4703
Practice Address - Country:US
Practice Address - Phone:813-972-8775
Practice Address - Fax:813-978-0680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF137709613140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10-5591Medicare ID - Type Unspecified