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General NPI Number Information
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NPI Number | 1205119609
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Entity Type | Organization
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Legal Business Name | ST BERNADETTE'S CARE LLC
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Dates
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Enumeration Date | 09/21/2011
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Last Update Date | 09/21/2011
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Provider Practice Location Address
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Address Line | 5448 LEGEND HILLS LN
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City | BROOKSVILLE
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State | FL
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Zip | 34609-9502
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Country | US
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Telephone | 352-593-4242
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 15669
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City | BROOKSVILLE
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State | FL
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Zip | 34604-0122
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Country | US
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Telephone | 352-593-4242
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOSE CERON-FUENTES
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Credential | M.D.
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Telephone | 352-593-4242
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number | ME95797
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License Number State | FL
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