Provider Demographics
NPI:1144582461
Name:WATERS EDGE OF BRADETON
Entity Type:Organization
Organization Name:WATERS EDGE OF BRADETON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, RMI, MANAGEMENT AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:JAQUES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-774-8878
Mailing Address - Street 1:2015 32ND AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-4505
Mailing Address - Country:US
Mailing Address - Phone:941-748-7797
Mailing Address - Fax:
Practice Address - Street 1:2015 32ND AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-4505
Practice Address - Country:US
Practice Address - Phone:941-748-7797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11742310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility