MEDICARE: ST BERNADETTE'S CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	ME95797	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205119609
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST BERNADETTE'S CARE LLC

Provider Business Mailing Address
First Line	:	PO BOX 15669
Second Line	:
City	:	BROOKSVILLE
State	:	FL
Zip	:	34604-0122
Country	:	US
Telephone Number	:	352-593-4242
Fax Number	:

Provider Business Practice Location Address
First Line	:	5448 LEGEND HILLS LN
Second Line	:
City	:	BROOKSVILLE
State	:	FL
Zip	:	34609-9502
Country	:	US
Telephone Number	:	352-593-4242
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOSE CERON-FUENTES
Credential	:	M.D.
Telephone Number	:	352-593-4242

Provider Enumeration Date	:	09/21/2011
Last Update Date	:	09/21/2011

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