Basic Information
| Provider Information | |||||||||
| NPI: | 1639412083 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GV LARGO, INC. | ||||||||
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| OtherOrganizationName: | GRAND VILLA OF LARGO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13770 58TH ST N | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337603759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277263980 | ||||||||
| FaxNumber: | 7277265345 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 STARKEY RD | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337712365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275860108 | ||||||||
| FaxNumber: | 7275866378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2013 | ||||||||
| LastUpdateDate: | 04/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | FORTE | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7277263980 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | AL7301 | FL | N | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 310400000X | AL7301 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 004211100 | 05 | FL | MEDICAID |