Basic Information
| Provider Information | |||||||||
| NPI: | 1194362491 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SH CARROLLWOOD, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE COLONNADE AT CARROLLWOOD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2573 BARRINGTON CIR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323086805 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 13550 S VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336188420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139085300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2019 | ||||||||
| LastUpdateDate: | 02/26/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | SETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8505837990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 104709800 | 05 | FL | MEDICAID | 9134 | 01 | FL | ALF LICENSE | OTHER |