Healthcare Provider Details

I. General information

NPI: 1619755691
Provider Name (Legal Business Name): 15TH STREET EAST SNF OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2023
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 15TH ST E
BRADENTON FL
34208-1337
US

IV. Provider business mailing address

105 15TH ST E
BRADENTON FL
34208-1337
US

V. Phone/Fax

Practice location:
  • Phone: 941-747-8681
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: AMITAI DAGAN
Title or Position: AUTHORIZED MEMBER
Credential:
Phone: 727-443-1588