Provider Demographics
NPI:1932101987
Name:SCG LAURELLWOOD LLC
Entity Type:Organization
Organization Name:SCG LAURELLWOOD LLC
Other - Org Name:LAURELLWOOD NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ROSS
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 1:3127 57TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33714
Practice Address - Country:US
Practice Address - Phone:727-527-2171
Practice Address - Fax:727-522-5929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031662800Medicaid
FL105228Medicare Oscar/Certification