MEDICARE: SENIOR CARE OF HIDDEN OAKS OPERATOR 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	5531	FL

General Provider Information

NPI Number	:	1104011873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SENIOR CARE OF HIDDEN OAKS OPERATOR LLC

Provider Business Mailing Address
First Line	:	1240 MARBELLA PLAZA DRIVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33619-7906
Country	:	US
Telephone Number	:	813-341-2700
Fax Number	:	813-651-4183

Provider Business Practice Location Address
First Line	:	3625 HIDDEN TREE LANE
Second Line	:
City	:	FORT MEYERS
State	:	FL
Zip	:	33901-8388
Country	:	US
Telephone Number	:	239-939-1393
Fax Number	:	239-939-1149

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MR. R DANIEL VAUGHAN
Credential	:
Telephone Number	:	813-341-2700

Provider Enumeration Date	:	09/06/2007
Last Update Date	:	09/06/2007

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