Basic Information
| Provider Information | |||||||||
| NPI: | 1619979747 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRADENTON COUNCIL ON AGING LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIVERFRONT NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1311 SW 16TH ST | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326081128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523768821 | ||||||||
| FaxNumber: | 3523763654 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 15TH ST E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342081337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417478681 | ||||||||
| FaxNumber: | 9417477091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 01/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | HURT | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3523768821 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | SNF1330096 | FL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 025994200 | 05 | FL | MEDICAID |