Provider Demographics
NPI:1821182544
Name:ST MARK VILLAGE INC
Entity Type:Organization
Organization Name:ST MARK VILLAGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:POHL
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:727-785-2577
Mailing Address - Street 1:2655 NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684
Mailing Address - Country:US
Mailing Address - Phone:727-785-2577
Mailing Address - Fax:727-786-6835
Practice Address - Street 1:2655 NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684
Practice Address - Country:US
Practice Address - Phone:727-785-2577
Practice Address - Fax:727-786-6835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1522096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031084100Medicaid
FL031084100Medicaid