Provider Demographics
NPI:1013913235
Name:SA-PG PINELLAS, LLC
Entity Type:Organization
Organization Name:SA-PG PINELLAS, LLC
Other - Org Name:PALM GARDEN OF PINELLAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WERTHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-390-4322
Mailing Address - Street 1:200 16TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33771-4400
Mailing Address - Country:US
Mailing Address - Phone:727-585-9377
Mailing Address - Fax:727-588-9038
Practice Address - Street 1:200 16TH AVE SE
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771-4400
Practice Address - Country:US
Practice Address - Phone:727-585-9377
Practice Address - Fax:727-588-9038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1418095314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025750800Medicaid
FL025750800Medicaid