Provider Demographics
NPI:1568755064
Name:CATHERINE MANOR, LLC
Entity Type:Organization
Organization Name:CATHERINE MANOR, LLC
Other - Org Name:BAY PINES MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:GRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-488-3520
Mailing Address - Street 1:10591 BAY PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33708-3101
Mailing Address - Country:US
Mailing Address - Phone:727-391-5965
Mailing Address - Fax:727-391-5965
Practice Address - Street 1:10591 BAY PINES BLVD
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33708-3101
Practice Address - Country:US
Practice Address - Phone:727-391-5965
Practice Address - Fax:727-391-5965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL7797310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL142048800Medicaid