Provider Demographics
NPI:1700209533
Name:GOLDEN AGE ALF OF TAMPA BAY, INC.
Entity Type:Organization
Organization Name:GOLDEN AGE ALF OF TAMPA BAY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:ALEJANDRO
Authorized Official - Last Name:TOLEDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-877-6581
Mailing Address - Street 1:3328 W SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-4225
Mailing Address - Country:US
Mailing Address - Phone:813-877-6581
Mailing Address - Fax:813-877-6584
Practice Address - Street 1:3328 W SPRUCE ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-4225
Practice Address - Country:US
Practice Address - Phone:813-877-6581
Practice Address - Fax:813-877-6584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12443310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility