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General NPI Number Information
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NPI Number | 1114472263
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Entity Type | Organization
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Legal Business Name | RUDY'S AGAPE HOUSE, LLC
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Dates
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Enumeration Date | 08/18/2016
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Last Update Date | 08/18/2016
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Provider Practice Location Address
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Address Line | 2104 55TH AVE W
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City | BRADENTON
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State | FL
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Zip | 34207-3240
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Country | US
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Telephone | 941-755-0225
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Fax | 941-460-4304
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Provider Business Mailing Address
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Address Line | 5426 18TH ST W
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City | BRADENTON
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State | FL
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Zip | 34207-3305
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Country | US
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Telephone | 941-756-0200
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Fax | 941-460-4304
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Authorized Official
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Title or Position | OWNER
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Name | NANCY E CUSHMAN
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Credential |
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Telephone | 941-756-0200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 12857
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License Number State | FL
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