MEDICARE: TIFFANY LAKE CARE CENTERS, 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	310400000X	Assisted Living Facility	8788	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	:	1225378730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIFFANY LAKE CARE CENTERS, INC

Provider Business Mailing Address
First Line	:	402 N RIVERSIDE DR
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-6740
Country	:	US
Telephone Number	:	386-423-1120
Fax Number	:

Provider Business Practice Location Address
First Line	:	402 N RIVERSIDE DR
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-6740
Country	:	US
Telephone Number	:	386-423-1120
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	MS. DESIREE A CULVER
Credential	:
Telephone Number	:	386-689-2030

Provider Enumeration Date	:	02/20/2013
Last Update Date	:	02/20/2013

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