Provider Demographics
NPI:1891127080
Name:EXTENDED CARE PORTFOLIO FLORIDA TENANT, LLC
Entity Type:Organization
Organization Name:EXTENDED CARE PORTFOLIO FLORIDA TENANT, LLC
Other - Org Name:PACIFICA SENIOR LIVING BELLAIR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:VARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-726-3980
Mailing Address - Street 1:13770 58TH ST N
Mailing Address - Street 2:SUITE 312
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-3759
Mailing Address - Country:US
Mailing Address - Phone:727-726-3980
Mailing Address - Fax:
Practice Address - Street 1:620 BELLEAIR RD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-2106
Practice Address - Country:US
Practice Address - Phone:727-467-9464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
FLAL 9666311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility