Healthcare Provider Details

I. General information

NPI: 1386213320
Provider Name (Legal Business Name): 202 BEVERLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 BEVERLY BLVD
BRANDON FL
33511-5504
US

IV. Provider business mailing address

202 BEVERLY BLVD
BRANDON FL
33511-5504
US

V. Phone/Fax

Practice location:
  • Phone: 678-255-5990
  • Fax:
Mailing address:
  • Phone: 813-655-8454
  • Fax: 813-315-9379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MILES RAYNOR JR.
Title or Position: CEO
Credential:
Phone: 678-255-5990