Provider Demographics
NPI:1306815147
Name:BRADFORD TERRACE LLC
Entity Type:Organization
Organization Name:BRADFORD TERRACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CF0
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-255-1054
Mailing Address - Street 1:808 COLLEY RD
Mailing Address - Street 2:
Mailing Address - City:STARKE
Mailing Address - State:FL
Mailing Address - Zip Code:32091-4215
Mailing Address - Country:US
Mailing Address - Phone:904-964-6220
Mailing Address - Fax:904-964-4446
Practice Address - Street 1:808 COLLEY RD
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-4215
Practice Address - Country:US
Practice Address - Phone:904-964-6220
Practice Address - Fax:904-964-4446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GU16030961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========Medicaid
FL=========Medicaid