Provider Demographics
NPI:1104418169
Name:TAMPA BAY SERVICES GROUP LLC
Entity type:Organization
Organization Name:TAMPA BAY SERVICES GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ISMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PADRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-382-1172
Mailing Address - Street 1:8313 W HILLSBOROUGH AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-3819
Mailing Address - Country:US
Mailing Address - Phone:813-382-1172
Mailing Address - Fax:
Practice Address - Street 1:8313 W HILLSBOROUGH AVE STE 110
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-3819
Practice Address - Country:US
Practice Address - Phone:813-382-1172
Practice Address - Fax:813-801-3044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-10
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109675200Medicaid