Provider Demographics
NPI:1023263274
Name:STONE LEDGE MANOR
Entity type:Organization
Organization Name:STONE LEDGE MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MALCOLM
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-986-7900
Mailing Address - Street 1:12006 MCINTOSH RD
Mailing Address - Street 2:
Mailing Address - City:THONOTOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:33592-3813
Mailing Address - Country:US
Mailing Address - Phone:813-986-7900
Mailing Address - Fax:
Practice Address - Street 1:12006 MCINTOSH RD
Practice Address - Street 2:
Practice Address - City:THONOTOSASSA
Practice Address - State:FL
Practice Address - Zip Code:33592-3813
Practice Address - Country:US
Practice Address - Phone:813-986-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11289310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility