Provider Demographics
NPI:1821006701
Name:SENIOR CARE GROUP
Entity Type:Organization
Organization Name:SENIOR CARE GROUP
Other - Org Name:LAKESHORE VILLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-968-5093
Mailing Address - Street 1:16002 LAKESHORE VILLA DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-1367
Mailing Address - Country:US
Mailing Address - Phone:813-968-5093
Mailing Address - Fax:813-264-0476
Practice Address - Street 1:16002 LAKESHORE VILLA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-1367
Practice Address - Country:US
Practice Address - Phone:813-968-5093
Practice Address - Fax:813-264-0476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1282096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105542Medicare ID - Type UnspecifiedMC PROVIDER #