MEDICARE: BRISTOL COURT ALF BSLC

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	11970	FL

General Provider Information

NPI Number	:	1669857264
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRISTOL COURT ALF BSLC

Provider Business Mailing Address
First Line	:	3479 54TH AVE N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33714-2426
Country	:	US
Telephone Number	:	727-580-8888
Fax Number	:	727-580-7777

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	:	727-580-8888
Fax Number	:	727-580-7777

Authorized Official
Title or Position	:	MGR
Name	:	LIZA ROJAS
Credential	:
Telephone Number	:	941-809-6147

Provider Enumeration Date	:	07/23/2015
Last Update Date	:	07/23/2015

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