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General NPI Number Information
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NPI Number | 1144582461
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Entity Type | Organization
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Legal Business Name | WATERS EDGE OF BRADETON
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Dates
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Enumeration Date | 06/12/2012
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Last Update Date | 06/12/2012
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Provider Practice Location Address
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Address Line | 2015 32ND AVE W
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City | BRADENTON
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State | FL
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Zip | 34205-4505
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Country | US
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Telephone | 941-748-7797
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Fax |
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Provider Business Mailing Address
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Address Line | 2015 32ND AVE W
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City | BRADENTON
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State | FL
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Zip | 34205-4505
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Country | US
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Telephone | 941-748-7797
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Fax |
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Authorized Official
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Title or Position | PRESIDENT, RMI, MANAGEMENT AGENT
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Name | JERRY JAQUES
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Credential |
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Telephone | 386-774-8878
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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 | AL11742
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License Number State | FL
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