Healthcare Provider Details

I. General information

NPI: 1306815147
Provider Name (Legal Business Name): BRADFORD TERRACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 COLLEY RD
STARKE FL
32091-4215
US

IV. Provider business mailing address

808 COLLEY RD
STARKE FL
32091-4215
US

V. Phone/Fax

Practice location:
  • Phone: 904-964-6220
  • Fax: 904-964-4446
Mailing address:
  • Phone: 904-964-6220
  • Fax: 904-964-4446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number16030961
License Number StateGU

VIII. Authorized Official

Name: MS. DONNA MARSH
Title or Position: CF0
Credential:
Phone: 386-255-1054