Provider Demographics
NPI:1770016701
Name:MAGGORIE SHORES HOME LLC
Entity Type:Organization
Organization Name:MAGGORIE SHORES HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-434-1828
Mailing Address - Street 1:PO BOX 15421
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-5421
Mailing Address - Country:US
Mailing Address - Phone:727-434-1828
Mailing Address - Fax:727-499-7943
Practice Address - Street 1:5566 MARTIN LUTHER KING ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-5139
Practice Address - Country:US
Practice Address - Phone:727-434-1828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home