Healthcare Provider Details

I. General information

NPI: 1053751693
Provider Name (Legal Business Name): 60TH AVENUE ALF, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 60TH AVE W
BRADENTON FL
34207-4324
US

IV. Provider business mailing address

8415 E 21ST ST N STE 100
WICHITA KS
67206-2959
US

V. Phone/Fax

Practice location:
  • Phone: 941-752-1990
  • Fax: 941-752-1740
Mailing address:
  • Phone: 316-616-6288
  • Fax: 316-616-6255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL9932
License Number StateFL

VIII. Authorized Official

Name: MR. CHRISTOPHER L WETTIG
Title or Position: CFO
Credential: CPA
Phone: 316-616-6288