Basic Information
Provider Information | |||||||||
NPI: | 1699728626 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOLOMON HOLDINGS I - THE TRIANGLE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BRIGHTON GARDEN OF TAMPA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7900 WESTPARK DR | ||||||||
Address2: | T-900, ATT: MEDICARE BILLING, M. GARCIA | ||||||||
City: | MC LEAN | ||||||||
State: | VA | ||||||||
PostalCode: | 221024242 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7038540823 | ||||||||
FaxNumber: | 7038540164 | ||||||||
Practice Location | |||||||||
Address1: | 16702 N DALE MABRY HWY | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336181055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8139082333 | ||||||||
FaxNumber: | 8139082244 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2006 | ||||||||
LastUpdateDate: | 12/06/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LANG | ||||||||
AuthorizedOfficialFirstName: | MERCILEC | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8139082333 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 12813 | FL | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.