Basic Information
| Provider Information | |||||||||
| NPI: | 1518968288 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SURREY PLACE OF BRADENTON LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SURREY PLACE CONV CENTER OF BRADENTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2123 CENTRE POINTE BLVD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8503862831 | ||||||||
| FaxNumber: | 8503862016 | ||||||||
| Practice Location | |||||||||
| Address1: | 5525 21ST AVE W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342095601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417950448 | ||||||||
| FaxNumber: | 9417574295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 03/18/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8503862831 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | FL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 025627700 | 05 | FL | MEDICAID |