MEDICARE: HOUSE OF BOSTICS LLC (THE)

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
2	3104A0625X	Assisted Living Facility (Mental Illness)

General Provider Information

NPI Number	:	1447870266
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOUSE OF BOSTICS LLC (THE)

Provider Business Mailing Address
First Line	:	3586 53RD AVE N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33714-2412
Country	:	US
Telephone Number	:	727-550-7076
Fax Number	:	727-329-9031

Provider Business Practice Location Address
First Line	:	3586 53RD AVE N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33714-2412
Country	:	US
Telephone Number	:	727-550-7076
Fax Number	:	727-329-9031

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	SHALONDRIA N BOSTIC
Credential	:
Telephone Number	:	727-550-7076

Provider Enumeration Date	:	04/22/2020
Last Update Date	:	11/23/2022

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Directions to “HOUSE OF BOSTICS LLC (THE) ” Practice Location

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