Healthcare Provider Details

I. General information

NPI: 1083170534
Provider Name (Legal Business Name): SF BREVARD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

298 SW PROSPERITY PLACE
LAKE CITY FL
32024
US

IV. Provider business mailing address

298 SW PROSPERITY PLACE
LAKE CITY FL
32024
US

V. Phone/Fax

Practice location:
  • Phone: 833-623-3093
  • Fax: 833-623-3093
Mailing address:
  • Phone: 833-623-3093
  • Fax: 833-623-3093

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: JAMES RICHARDSON
Title or Position: PRESIDENT
Credential:
Phone: 850-430-0000