MEDICARE: BRISTOL PLC 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1386158806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRISTOL PLC LLC

Provider Business Mailing Address
First Line	:	3630 ILLINOIS RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2062
Country	:	US
Telephone Number	:	260-797-9482
Fax Number	:

Provider Business Practice Location Address
First Line	:	3479 54TH AVE N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33714-2426
Country	:	US
Telephone Number	:	727-520-8888
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER/COO
Name	:	MR. ROBERT EDWARD PETRAS JR.
Credential	:
Telephone Number	:	260-797-9482

Provider Enumeration Date	:	11/20/2017
Last Update Date	:	11/20/2017

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