Provider Demographics
NPI:1558667279
Name:SOUTHERN PARKS INC
Entity Type:Organization
Organization Name:SOUTHERN PARKS INC
Other - Org Name:SOUTHERN OAKS ALF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SANNY
Authorized Official - Middle Name:PRADO
Authorized Official - Last Name:PANINGBATAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-773-9557
Mailing Address - Street 1:157 WILL DUKES RD
Mailing Address - Street 2:
Mailing Address - City:WAUCHULA
Mailing Address - State:FL
Mailing Address - Zip Code:33873-9308
Mailing Address - Country:US
Mailing Address - Phone:863-773-9557
Mailing Address - Fax:863-773-0764
Practice Address - Street 1:157 WILL DUKES RD
Practice Address - Street 2:
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873-9308
Practice Address - Country:US
Practice Address - Phone:863-773-9557
Practice Address - Fax:863-773-0764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-27
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL78533104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL140885200Medicaid