Provider Demographics
NPI:1184616245
Name:SCG HARBOURWOOD LLC
Entity type:Organization
Organization Name:SCG HARBOURWOOD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-341-2700
Mailing Address - Street 1:1240 MARBELLA PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619
Mailing Address - Country:US
Mailing Address - Phone:813-341-2700
Mailing Address - Fax:813-341-2755
Practice Address - Street 1:2855 GULF TO BAY BLVD
Practice Address - Street 2:BLDG #31
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-4087
Practice Address - Country:US
Practice Address - Phone:727-724-6800
Practice Address - Fax:727-724-6848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031663600Medicaid
FLM3KOtherBLUE CROSS AND BLUE SHIELD
FLM3KOtherBLUE CROSS AND BLUE SHIELD