MEDICARE: PALMS VILLA RETIREMENT HOME, INC.

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	3104A0625X	Assisted Living Facility (Mental Illness)	AL4990	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

General Provider Information

NPI Number	:	1083866818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALMS VILLA RETIREMENT HOME, INC.

Provider Business Mailing Address
First Line	:	2131 NW 28TH ST
Second Line	:
City	:	OAKLAND PARK
State	:	FL
Zip	:	33311-2136
Country	:	US
Telephone Number	:	954-484-1350
Fax Number	:	954-527-0505

Provider Business Practice Location Address
First Line	:	2131 NW 28TH ST
Second Line	:
City	:	OAKLAND PARK
State	:	FL
Zip	:	33311-2136
Country	:	US
Telephone Number	:	954-484-1350
Fax Number	:	954-527-0505

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JASON KISSOONLAL
Credential	:
Telephone Number	:	954-484-1350

Provider Enumeration Date	:	10/10/2008
Last Update Date	:	08/26/2020

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