Provider Demographics
NPI:1205119609
Name:ST BERNADETTE'S CARE LLC
Entity type:Organization
Organization Name:ST BERNADETTE'S CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:CERON-FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-593-4242
Mailing Address - Street 1:PO BOX 15669
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34604-0122
Mailing Address - Country:US
Mailing Address - Phone:352-593-4242
Mailing Address - Fax:
Practice Address - Street 1:5448 LEGEND HILLS LN
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34609-9502
Practice Address - Country:US
Practice Address - Phone:352-593-4242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95797207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2775247Medicaid
FL2775247Medicaid