Provider Demographics
NPI:1760479901
Name:JOHN KNOX VILLAGE OF TAMPA BAY INC
Entity Type:Organization
Organization Name:JOHN KNOX VILLAGE OF TAMPA BAY INC
Other - Org Name:ST. JOSEPH'S JOHN KNOX VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:VICARIO
Authorized Official - Last Name:LYONS
Authorized Official - Suffix:
Authorized Official - Credentials:NHA, CPA
Authorized Official - Phone:813-632-2391
Mailing Address - Street 1:4100 E. FLETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4863
Mailing Address - Country:US
Mailing Address - Phone:813-632-2455
Mailing Address - Fax:813-632-2388
Practice Address - Street 1:4100 E. FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4863
Practice Address - Country:US
Practice Address - Phone:813-632-2455
Practice Address - Fax:813-632-2388
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JOSEPH'S HEALTH CARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-03
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL4110310400000X
FLSNF1260095314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021028500Medicaid
FLK68OtherBLUECROSS BLUESHIELD
FL0673320001Medicare NSC
FL105351Medicare Oscar/Certification