Provider Demographics
NPI:1205664349
Name:3455 SAN PABLO RD S TENANT LLC
Entity type:Organization
Organization Name:3455 SAN PABLO RD S TENANT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:MAKOWSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-247-2800
Mailing Address - Street 1:8415 E 21ST ST N STE 100
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2959
Mailing Address - Country:US
Mailing Address - Phone:316-616-6288
Mailing Address - Fax:
Practice Address - Street 1:3455 SAN PABLO RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-3803
Practice Address - Country:US
Practice Address - Phone:904-821-8030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)