=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124346820
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WARES CREEK ALF OPERATING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2010
-----------------------------------------------------
Last Update Date | 05/06/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1725 MANATEE AVE W
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34205-5924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-746-5226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1725 MANATEE AVE W
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34205-5924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-746-5226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. STEVE SCHROEDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 941-746-5226
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL10653
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------