Provider Demographics
NPI:1689114787
Name:SILVER LAKE ALF
Entity Type:Organization
Organization Name:SILVER LAKE ALF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ASRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-410-0828
Mailing Address - Street 1:3211 W SITKA ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-2701
Mailing Address - Country:US
Mailing Address - Phone:813-410-0828
Mailing Address - Fax:813-999-4036
Practice Address - Street 1:3211 W SITKA ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2701
Practice Address - Country:US
Practice Address - Phone:813-410-0828
Practice Address - Fax:813-999-4036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11512310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009213400Medicaid