Provider Demographics
NPI:1871926295
Name:SANDRA ADULT FAMILY CARE HOME
Entity type:Organization
Organization Name:SANDRA ADULT FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SALOMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-476-8875
Mailing Address - Street 1:1004 LARWOOD PINE DR
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33570-5334
Mailing Address - Country:US
Mailing Address - Phone:813-476-8875
Mailing Address - Fax:
Practice Address - Street 1:1004 LARWOOD PINE DR
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33570-5334
Practice Address - Country:US
Practice Address - Phone:813-476-8875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-21
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906469311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003716200Medicaid