Provider Demographics
NPI:1013904234
Name:BON SECOURS - MARIA MANOR NURSING CARE CENTER LLC
Entity Type:Organization
Organization Name:BON SECOURS - MARIA MANOR NURSING CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SYSTEM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:RALSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-996-5119
Mailing Address - Street 1:10300 4TH ST NORTH
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-3810
Mailing Address - Country:US
Mailing Address - Phone:727-568-1000
Mailing Address - Fax:727-568-1088
Practice Address - Street 1:10300 4TH ST NORTH
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-3810
Practice Address - Country:US
Practice Address - Phone:727-568-1000
Practice Address - Fax:727-568-1088
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS HEALTH SYSTEMS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1055096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020010700Medicaid
FL020010700Medicaid