Provider Demographics
NPI:1922394246
Name:SOUTHERN COMFORT INN BED AND BREAKFAST
Entity Type:Organization
Organization Name:SOUTHERN COMFORT INN BED AND BREAKFAST
Other - Org Name:SOUTHERN COMFORT INN ADULT DAY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-645-6361
Mailing Address - Street 1:2409 W RAVINE DR
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33570-5635
Mailing Address - Country:US
Mailing Address - Phone:813-645-6361
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:813-645-6361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-24
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBNB3911919310400000X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home