Provider Demographics
NPI:1912330424
Name:EXTENDED CARE PORTFOLIO TENANT, LLC
Entity type:Organization
Organization Name:EXTENDED CARE PORTFOLIO TENANT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-726-3980
Mailing Address - Street 1:13770 58TH ST N
Mailing Address - Street 2:SUITE 312
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-3759
Mailing Address - Country:US
Mailing Address - Phone:727-726-3980
Mailing Address - Fax:
Practice Address - Street 1:3207 N MONROE ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-2832
Practice Address - Country:US
Practice Address - Phone:850-562-4123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL99310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility