Provider Demographics
NPI:1649227414
Name:MANOR CARE - CARROLLWOOD OF TAMPA FL, LLC
Entity Type:Organization
Organization Name:MANOR CARE - CARROLLWOOD OF TAMPA FL, LLC
Other - Org Name:MANORCARE HEALTH SERVICES-CARROLLWOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-252-5734
Mailing Address - Street 1:333 N SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-2615
Mailing Address - Country:US
Mailing Address - Phone:419-252-5500
Mailing Address - Fax:877-385-9446
Practice Address - Street 1:3030 W BEARSS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-1811
Practice Address - Country:US
Practice Address - Phone:813-968-8777
Practice Address - Fax:813-961-5189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2017-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1315096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL032567800Medicaid
FL105700Medicare Oscar/Certification