Provider Demographics
NPI:1013473024
Name:GREEN SENIOR CARE OF TAMPA LLC
Entity Type:Organization
Organization Name:GREEN SENIOR CARE OF TAMPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:DEWITT
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-731-8312
Mailing Address - Street 1:11290 WALSINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33778-3101
Mailing Address - Country:US
Mailing Address - Phone:855-331-6615
Mailing Address - Fax:855-638-4902
Practice Address - Street 1:1513 W FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-3315
Practice Address - Country:US
Practice Address - Phone:855-331-6615
Practice Address - Fax:855-638-4902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility