Healthcare Provider Details

I. General information

NPI: 1043523392
Provider Name (Legal Business Name): JOSEPH STOREHOUSE OF FLORIDA RESTORATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 9TH ST W
BRADENTON FL
34205-7330
US

IV. Provider business mailing address

1027 9TH ST W
BRADENTON FL
34205-7330
US

V. Phone/Fax

Practice location:
  • Phone: 941-708-3030
  • Fax: 941-708-3838
Mailing address:
  • Phone:
  • Fax: 941-708-3838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number1258AD488301
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. ALPHONSO DAVIS
Title or Position: CEO/LIASON
Credential:
Phone: 941-708-3030