=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417361858
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CCRC OPCO - BRADENTON, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2014
-----------------------------------------------------
Last Update Date | 05/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6410 21ST AVE W
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34209-7854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-798-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1920 MAIN ST STE 1200
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92614-7230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-407-0700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | STEVEN LOVATO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 941-798-8190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------