Provider Demographics
NPI:1528400769
Name:BRADFORD HOMELIVING LLC
Entity Type:Organization
Organization Name:BRADFORD HOMELIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:COREY
Authorized Official - Middle Name:LENNARD
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-237-0206
Mailing Address - Street 1:2335 SOUTEL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-2171
Mailing Address - Country:US
Mailing Address - Phone:904-237-0206
Mailing Address - Fax:904-619-8391
Practice Address - Street 1:2335 SOUTEL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-2171
Practice Address - Country:US
Practice Address - Phone:904-237-0206
Practice Address - Fax:904-619-8391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-29
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12318310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility