Provider Demographics
NPI:1619416609
Name:SOUTHERN COMFORT FAMILY SERVICES
Entity Type:Organization
Organization Name:SOUTHERN COMFORT FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLADYS
Authorized Official - Middle Name:'LADONNA'
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-812-7799
Mailing Address - Street 1:235 APOLLO BEACH BLVD
Mailing Address - Street 2:228
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-2251
Mailing Address - Country:US
Mailing Address - Phone:813-784-7737
Mailing Address - Fax:
Practice Address - Street 1:2409 W RAVINE DR
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33570-5635
Practice Address - Country:US
Practice Address - Phone:813-784-7737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12937310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility