Provider Demographics
NPI:1306361266
Name:VALDES, LARRY (CEO)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:VALDES
Suffix:
Gender:M
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4402 W MINNEHAHA ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-3638
Mailing Address - Country:US
Mailing Address - Phone:813-841-9823
Mailing Address - Fax:813-349-0029
Practice Address - Street 1:4402 W MINNEHAHA ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614
Practice Address - Country:US
Practice Address - Phone:813-841-9823
Practice Address - Fax:813-349-0029
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33614Medicaid