Provider Demographics
NPI:1457754558
Name:GV ST. PETE, LLC
Entity Type:Organization
Organization Name:GV ST. PETE, LLC
Other - Org Name:GRAND VILLA OF ST. PETERSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-726-3980
Mailing Address - Street 1:3600 34TH ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-3800
Mailing Address - Country:US
Mailing Address - Phone:727-350-5830
Mailing Address - Fax:
Practice Address - Street 1:13770 58TH ST N
Practice Address - Street 2:SUITE 312
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-3759
Practice Address - Country:US
Practice Address - Phone:727-726-3980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12561310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility