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General NPI Number Information
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NPI Number | 1336747658
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Entity Type | Individual
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Provider Name | EDDRENA THORNTON OWNER
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Gender | Female
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Dates
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Enumeration Date | 10/09/2020
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Last Update Date | 10/10/2020
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Provider Practice Location Address
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Address Line | 2233 BLUEBIRD AVE
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City | BARTOW
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State | FL
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Zip | 33830-2953
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Country | US
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Telephone | 863-529-3103
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Fax |
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Provider Business Mailing Address
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Address Line | 2233 BLUEBIRD AVE
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City | BARTOW
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State | FL
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Zip | 33830-2953
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Country | US
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Telephone | 863-529-3103
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | 6907032
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License Number State | FL
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