MEDICARE: SOUTHERN COMFORT INN BED AND BREAKFAST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility	BNB3911919	FL
2	310400000X	Assisted Living Facility	BNB3911919	FL

General Provider Information

NPI Number	:	1922394246
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN COMFORT INN BED AND BREAKFAST

Provider Business Mailing Address
First Line	:	2409 W RAVINE DR
Second Line	:
City	:	RUSKIN
State	:	FL
Zip	:	33570-5635
Country	:	US
Telephone Number	:	813-645-6361
Fax Number	:

Provider Business Practice Location Address
First Line	:	2409 W RAVINE DR
Second Line	:
City	:	RUSKIN
State	:	FL
Zip	:	33570-5635
Country	:	US
Telephone Number	:	813-645-6361
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JOE GREEN
Credential	:
Telephone Number	:	813-645-6361

Provider Enumeration Date	:	06/24/2011
Last Update Date	:	06/24/2011

Similar Medicare Providers

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Practice Location Address:

2409 W RAVINE DR
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1265060461 — AKSHAYA KANNAN SINGH MD
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1356346340 — DR. AURA MARIA CISNEROS D.M.D
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Practice Location Address:

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Directions to “SOUTHERN COMFORT INN BED AND BREAKFAST ” Practice Location

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