Provider Demographics
NPI:1366123697
Name:SWEET WATER GRAND LLC
Entity type:Organization
Organization Name:SWEET WATER GRAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:DEWITT
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-731-8312
Mailing Address - Street 1:134 8TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3616
Mailing Address - Country:US
Mailing Address - Phone:813-731-8312
Mailing Address - Fax:
Practice Address - Street 1:11202 DEWHURST DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-4286
Practice Address - Country:US
Practice Address - Phone:813-731-8312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility