Healthcare Provider Details

I. General information

NPI: 1770016701
Provider Name (Legal Business Name): MAGGORIE SHORES HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 04/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5566 MARTIN LUTHER KING ST S
ST PETERSBURG FL
33705-5139
US

IV. Provider business mailing address

PO BOX 15421
ST PETERSBURG FL
33733-5421
US

V. Phone/Fax

Practice location:
  • Phone: 727-434-1828
  • Fax:
Mailing address:
  • Phone: 727-434-1828
  • Fax: 727-499-7943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. TODD E BRIDGES
Title or Position: OWNER
Credential:
Phone: 727-434-1828