Provider Demographics
NPI:1053312165
Name:BRADENTON COUNCIL ON AGING LLC
Entity Type:Organization
Organization Name:BRADENTON COUNCIL ON AGING LLC
Other - Org Name:THE VERANDAS AT RIVERFRONT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:ECKLOF
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:352-376-8821
Mailing Address - Street 1:1311 SW 16TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-1128
Mailing Address - Country:US
Mailing Address - Phone:352-376-8821
Mailing Address - Fax:352-376-3654
Practice Address - Street 1:105 15TH ST E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1337
Practice Address - Country:US
Practice Address - Phone:941-750-9691
Practice Address - Fax:941-750-9554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL8659310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL687305700Medicaid
FL141883100Medicaid