Healthcare Provider Details

I. General information

NPI: 1922394246
Provider Name (Legal Business Name): SOUTHERN COMFORT INN BED AND BREAKFAST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2011
Last Update Date: 06/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2409 W RAVINE DR
RUSKIN FL
33570-5635
US

IV. Provider business mailing address

2409 W RAVINE DR
RUSKIN FL
33570-5635
US

V. Phone/Fax

Practice location:
  • Phone: 813-645-6361
  • Fax:
Mailing address:
  • Phone: 813-645-6361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberBNB3911919
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberBNB3911919
License Number StateFL

VIII. Authorized Official

Name: MR. JOE GREEN
Title or Position: OWNER
Credential:
Phone: 813-645-6361