=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285238758
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAITHFUL FRIENDS LOVING CARE ASSISTED LIVING CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2020
-----------------------------------------------------
Last Update Date | 11/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 49TH ST NW
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34209-1922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-237-8174
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 323 49TH AVE ST NW
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-237-8174
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. RUTHE GUILLAURY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 941-237-8174
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------