MEDICARE: CARMITA'S ASSISTING LIVING FACILITY III LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	AL12312	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013385491
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARMITA'S ASSISTING LIVING FACILITY III LLC

Provider Business Mailing Address
First Line	:	939 PARK MANOR DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32825-6744
Country	:	US
Telephone Number	:	407-432-6785
Fax Number	:	407-897-7452

Provider Business Practice Location Address
First Line	:	939 PARK MANOR DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32825-6744
Country	:	US
Telephone Number	:	407-432-6785
Fax Number	:	407-897-7452

Authorized Official
Title or Position	:	OWNER
Name	:	JESUS PRIETO
Credential	:
Telephone Number	:	407-432-6785

Provider Enumeration Date	:	09/02/2015
Last Update Date	:	09/02/2015

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