Healthcare Provider Details

I. General information

NPI: 1245225960
Provider Name (Legal Business Name): BRADENTON ENTERPRISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 MANATEE AVE E
BRADENTON FL
34208-1560
US

IV. Provider business mailing address

2010 MANATEE AVE E
BRADENTON FL
34208-1560
US

V. Phone/Fax

Practice location:
  • Phone: 941-747-3706
  • Fax: 941-746-7785
Mailing address:
  • Phone: 941-747-3706
  • Fax: 941-746-7785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF15320961
License Number StateFL

VIII. Authorized Official

Name: RANDY KRUGER
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 941-747-3706