Basic Information
| Provider Information | |||||||||
| NPI: | 1083092035 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERFRONT ACQUISITION I LLC | ||||||||
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| OtherOrganizationName: | RESIDENCE AT BAY VUE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7751 W BROWARD BLVD | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333242003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544738040 | ||||||||
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| Practice Location | |||||||||
| Address1: | 105 15TH ST E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342081337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417478681 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2015 | ||||||||
| LastUpdateDate: | 05/11/2015 | ||||||||
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| AuthorizedOfficialLastName: | FEMINELLA | ||||||||
| AuthorizedOfficialFirstName: | DANIELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9144711022 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 011159600 | 05 | FL | MEDICAID |