Provider Demographics
NPI:1336747658
Name:THORNTON, EDDRENA (OWNER)
Entity Type:Individual
Prefix:
First Name:EDDRENA
Middle Name:
Last Name:THORNTON
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 BLUEBIRD AVE
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-2953
Mailing Address - Country:US
Mailing Address - Phone:863-529-3103
Mailing Address - Fax:
Practice Address - Street 1:2233 BLUEBIRD AVE
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-2953
Practice Address - Country:US
Practice Address - Phone:863-529-3103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6907032311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home