Provider Demographics
NPI:1346238631
Name:SENIOR CARE SOUTHERN PINES LLC
Entity type:Organization
Organization Name:SENIOR CARE SOUTHERN PINES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT AND COO
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:L
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:615-771-7575
Mailing Address - Street 1:6140 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-3909
Mailing Address - Country:US
Mailing Address - Phone:727-842-8402
Mailing Address - Fax:727-841-8060
Practice Address - Street 1:6140 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-3909
Practice Address - Country:US
Practice Address - Phone:727-842-8402
Practice Address - Fax:727-841-8060
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVOCAT INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-11
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF15060961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4890900001Medicare NSC
FL10-5275Medicare PIN