Provider Demographics
NPI:1912322801
Name:GENESIS ALF OF TAMPA BAY, INC
Entity type:Organization
Organization Name:GENESIS ALF OF TAMPA BAY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MISS
Authorized Official - First Name:GLADYS
Authorized Official - Middle Name:
Authorized Official - Last Name:KANODEREKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-638-5803
Mailing Address - Street 1:714 VILLAGE PL
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:714 VILLAGE PL
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6240
Practice Address - Country:US
Practice Address - Phone:813-638-5803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)