MEDICARE: FLORIDA MENTOR II 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	315P00000X	Intellectual Disabilities Intermediate Care Facility

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	:	1144827288
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA MENTOR II LLC

Provider Business Mailing Address
First Line	:	3258 PARKSIDE CENTER CIR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33619-0907
Country	:	US
Telephone Number	:	813-389-8300
Fax Number	:

Provider Business Practice Location Address
First Line	:	455 APPLEYARD DR
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32304-2808
Country	:	US
Telephone Number	:	850-575-0619
Fax Number	:	850-576-5773

Authorized Official
Title or Position	:	VICE PRESIDENT OF OPERATIONS
Name	:	CAROL SWANSON
Credential	:
Telephone Number	:	813-389-8300

Provider Enumeration Date	:	10/01/2020
Last Update Date	:	11/18/2020

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Directions to “FLORIDA MENTOR II LLC ” Practice Location

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