Provider Demographics
NPI:1902404668
Name:TAMBOLINA SERVICES COMMUNITY RESIDENT HOME, INC
Entity Type:Organization
Organization Name:TAMBOLINA SERVICES COMMUNITY RESIDENT HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMBA
Authorized Official - Middle Name:MEDZA
Authorized Official - Last Name:MOMORIE
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:904-629-9922
Mailing Address - Street 1:6285 CRANBERRY LN W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-2559
Mailing Address - Country:US
Mailing Address - Phone:904-651-1310
Mailing Address - Fax:904-240-0309
Practice Address - Street 1:6285 CRANBERRY LN W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-2559
Practice Address - Country:US
Practice Address - Phone:904-651-1310
Practice Address - Fax:904-240-0309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility