Healthcare Provider Details

I. General information

NPI: 1720402902
Provider Name (Legal Business Name): GENESIS ALF OF BRANDON, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2014
Last Update Date: 02/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 VILLAGE PL
BRANDON FL
33511-6240
US

IV. Provider business mailing address

714 VILLAGE PL
BRANDON FL
33511-6240
US

V. Phone/Fax

Practice location:
  • Phone: 863-425-3305
  • Fax: 888-371-6124
Mailing address:
  • Phone: 863-425-3305
  • Fax: 888-371-6124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number12132
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number12132
License Number StateFL

VIII. Authorized Official

Name: MRS. FELECIA RAMBERT
Title or Position: ADMINISTRATOR
Credential:
Phone: 863-425-3305