Provider Demographics
NPI:1629074851
Name:SA PG-TAMPA LLC
Entity Type:Organization
Organization Name:SA PG-TAMPA LLC
Other - Org Name:PALM GARDEN OF TAMPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:PALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-390-4363
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:2005-06-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1420095314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025752400Medicaid
FL025752400Medicaid