Provider Demographics
NPI:1609117621
Name:LORRAINE ASSISTED CARE DBA MELISSA ANN BONGART
Entity Type:Organization
Organization Name:LORRAINE ASSISTED CARE DBA MELISSA ANN BONGART
Other - Org Name:MELISSA ANN BONGART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BONGART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-504-9412
Mailing Address - Street 1:5916 LORRAINE ROAD
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211
Mailing Address - Country:US
Mailing Address - Phone:941-504-9412
Mailing Address - Fax:
Practice Address - Street 1:5916 LORRAINE RD
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34211-9208
Practice Address - Country:US
Practice Address - Phone:941-504-9412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-15
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906389311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004043700Medicaid