Provider Demographics
NPI:1982061644
Name:THONOTOSASSA, FL OPCO, LLC
Entity Type:Organization
Organization Name:THONOTOSASSA, FL OPCO, LLC
Other - Org Name:STONE LEDGE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-724-8950
Mailing Address - Street 1:1633 N CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5203
Mailing Address - Country:US
Mailing Address - Phone:312-724-8950
Mailing Address - Fax:
Practice Address - Street 1:12006 MCINTOSH RD
Practice Address - Street 2:
Practice Address - City:THONOTOSASSA
Practice Address - State:FL
Practice Address - Zip Code:33592-3838
Practice Address - Country:US
Practice Address - Phone:813-986-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility