Provider Demographics
NPI:1407128234
Name:SILVER WINGS INDEPENDENCE AT HOME LLC
Entity Type:Organization
Organization Name:SILVER WINGS INDEPENDENCE AT HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:MILTON
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-548-1232
Mailing Address - Street 1:6279 PARK BLVD N
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-3239
Mailing Address - Country:US
Mailing Address - Phone:727-548-1232
Mailing Address - Fax:727-548-1182
Practice Address - Street 1:6279 PARK BLVD N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-3239
Practice Address - Country:US
Practice Address - Phone:727-548-1232
Practice Address - Fax:727-548-1182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68819207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty