Provider Demographics
NPI:1972700169
Name:JOHNNIE B BYRD SR ALZHEIMERS CENTER AND RESEARCH INSTITUTE
Entity type:Organization
Organization Name:JOHNNIE B BYRD SR ALZHEIMERS CENTER AND RESEARCH INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:LILLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HO - PEHLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-866-1610
Mailing Address - Street 1:4001 E FLETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4808
Mailing Address - Country:US
Mailing Address - Phone:813-866-1611
Mailing Address - Fax:813-866-1612
Practice Address - Street 1:4001 E FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4808
Practice Address - Country:US
Practice Address - Phone:813-866-1611
Practice Address - Fax:813-866-1612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 74291041C0700X
FLME313002084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME31300OtherBALEBAIL ASHOK RAJ, M.D.
FLSW 7429OtherNANCY ANN TETEN, LCSW,CAP