Provider Demographics
NPI:1114472263
Name:RUDY'S AGAPE HOUSE, LLC
Entity Type:Organization
Organization Name:RUDY'S AGAPE HOUSE, LLC
Other - Org Name:RUDY'S AGAPE HOUSE II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:E
Authorized Official - Last Name:CUSHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-756-0200
Mailing Address - Street 1:5426 18TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-3305
Mailing Address - Country:US
Mailing Address - Phone:941-756-0200
Mailing Address - Fax:941-460-4304
Practice Address - Street 1:2104 55TH AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-3240
Practice Address - Country:US
Practice Address - Phone:941-755-0225
Practice Address - Fax:941-460-4304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12857310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004296700Medicaid