Provider Demographics
NPI:1407381163
Name:A BRIDGE FOR INDEPENDENCE PLUS LLC
Entity Type:Organization
Organization Name:A BRIDGE FOR INDEPENDENCE PLUS LLC
Other - Org Name:CROTON MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:STANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSBA, QMHP
Authorized Official - Phone:941-960-3222
Mailing Address - Street 1:7723 HOLIDAY DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-5313
Mailing Address - Country:US
Mailing Address - Phone:941-960-3222
Mailing Address - Fax:
Practice Address - Street 1:2512 CROTON AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-4907
Practice Address - Country:US
Practice Address - Phone:941-927-0139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLALFAL8427310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020223800Medicaid