MEDICARE: SHARICKS DECK RETIREMENT RANCH

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	AL5335	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	:	1184853640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHARICKS DECK RETIREMENT RANCH

Provider Business Mailing Address
First Line	:	4506 BRUTON RD
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33565-7029
Country	:	US
Telephone Number	:	813-754-5223
Fax Number	:	813-752-9265

Provider Business Practice Location Address
First Line	:	4506 BRUTON RD
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33565-7029
Country	:	US
Telephone Number	:	813-754-5223
Fax Number	:	813-752-9265

Authorized Official
Title or Position	:	OWNER
Name	:	MR. NICOLAS ANTONIO CICCARELLO
Credential	:
Telephone Number	:	813-754-5223

Provider Enumeration Date	:	07/06/2009
Last Update Date	:	06/17/2015

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