Provider Demographics
NPI:1841275195
Name:SALEM VILLAGES INCORPORATED HOLLY POINT PROPERTIES INC
Entity type:Organization
Organization Name:SALEM VILLAGES INCORPORATED HOLLY POINT PROPERTIES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVERN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-956-6956
Mailing Address - Street 1:4610 S MANHATTAN AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-2308
Mailing Address - Country:US
Mailing Address - Phone:813-839-5311
Mailing Address - Fax:813-839-4728
Practice Address - Street 1:4610 S MANHATTAN AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-2308
Practice Address - Country:US
Practice Address - Phone:813-839-5311
Practice Address - Fax:813-839-4728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF30470961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022491000Medicaid
FL5090090001Medicare NSC
FL105491Medicare Oscar/Certification