MEDICARE: SENIOR LIVING AGENCY

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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1093120354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SENIOR LIVING AGENCY

Provider Business Mailing Address
First Line	:	414 N WEST ST
Second Line	:
City	:	BAINBRIDGE
State	:	GA
Zip	:	39817-3678
Country	:	US
Telephone Number	:	229-515-6113
Fax Number	:	229-299-8689

Provider Business Practice Location Address
First Line	:	414 N WEST ST
Second Line	:
City	:	BAINBRIDGE
State	:	GA
Zip	:	39817-3678
Country	:	US
Telephone Number	:	229-515-6113
Fax Number	:	229-299-8689

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. SHANNA LATOYA SENIOR
Credential	:
Telephone Number	:	229-515-6113

Provider Enumeration Date	:	06/25/2014
Last Update Date	:	06/25/2014

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