Healthcare Provider Details

I. General information

NPI: 1922421270
Provider Name (Legal Business Name): RUDY'S AGAPE HOUSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5426 18TH ST W
BRADENTON FL
34207-3305
US

IV. Provider business mailing address

5426 18TH ST W
BRADENTON FL
34207-3305
US

V. Phone/Fax

Practice location:
  • Phone: 941-756-0200
  • Fax: 941-460-4304
Mailing address:
  • Phone: 941-756-0200
  • Fax: 941-460-4304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number10666
License Number StateFL

VIII. Authorized Official

Name: NANCY E CUSHMAN
Title or Position: ADMINISTRATOR/OWNER
Credential: CORE
Phone: 941-756-0200