Provider Demographics
NPI:1306199849
Name:BRADEN RIVER REHABILITATION CENTER, LLC
Entity type:Organization
Organization Name:BRADEN RIVER REHABILITATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:R.
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:CRONQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-574-2100
Mailing Address - Street 1:5887 GLENRIDGE DR NE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5574
Mailing Address - Country:US
Mailing Address - Phone:404-574-2100
Mailing Address - Fax:404-574-2105
Practice Address - Street 1:2010 MANATEE AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1560
Practice Address - Country:US
Practice Address - Phone:941-747-3706
Practice Address - Fax:941-746-7785
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOVEREIGN HEALTHCARE HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-22
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL314000000X
FLSNF15320961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007332400Medicaid
FL105045Medicare Oscar/Certification