Provider Demographics
NPI:1184045890
Name:SRI OF BRANDON MC, LLC
Entity Type:Organization
Organization Name:SRI OF BRANDON MC, LLC
Other - Org Name:SUPERIOR RESIDENCES OF BRANDON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CIO
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCARTHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-686-3831
Mailing Address - Street 1:1819 PROVIDENCE RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-1899
Mailing Address - Country:US
Mailing Address - Phone:813-657-8587
Mailing Address - Fax:
Practice Address - Street 1:1819 PROVIDENCE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-1899
Practice Address - Country:US
Practice Address - Phone:813-657-8587
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUPERIOR RESIDENCES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-23
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9739310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9739OtherAHCA