MEDICARE: BRUISED BUT NOT DESTROYED INC

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	315P00000X	Intellectual Disabilities Intermediate Care Facility
2	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1982461828
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRUISED BUT NOT DESTROYED INC

Provider Business Mailing Address
First Line	:	653 ORISTA DR
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33897-9589
Country	:	US
Telephone Number	:	813-928-8177
Fax Number	:

Provider Business Practice Location Address
First Line	:	653 ORISTA DR
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33897-9589
Country	:	US
Telephone Number	:	813-928-8177
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. TANIKA STEWART
Credential	:
Telephone Number	:	813-928-8177

Provider Enumeration Date	:	03/05/2024
Last Update Date	:	03/05/2024

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