Basic Information
| Provider Information | |||||||||
| NPI: | 1700226883 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GV PINELLAS PARK, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GRAND VILLA OF PINELLAS PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 13770 58TH STREET NORTH | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277263980 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8980 49TH STREET NORTH | ||||||||
| Address2: | |||||||||
| City: | PINELLAS PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275464053 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2013 | ||||||||
| LastUpdateDate: | 07/03/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PLUMMER | ||||||||
| AuthorizedOfficialFirstName: | NIKI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7277263980 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | 5487 | FL | N | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 310400000X | 5489 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.