MEDICARE: HOLMES CREEK ASSISTED LIVING FACILITY, 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	3104A0625X	Assisted Living Facility (Mental Illness)	AL5584	FL

General Provider Information

NPI Number	:	1326351545
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLMES CREEK ASSISTED LIVING FACILITY, INC.

Provider Business Mailing Address
First Line	:	PO BOX 390
Second Line	:
City	:	VERNON
State	:	FL
Zip	:	32462-0390
Country	:	US
Telephone Number	:	850-535-1160
Fax Number	:

Provider Business Practice Location Address
First Line	:	3732 ROCHE AVE
Second Line	:
City	:	VERNON
State	:	FL
Zip	:	32462-3373
Country	:	US
Telephone Number	:	850-535-1160
Fax Number	:	850-535-4713

Authorized Official
Title or Position	:	PRESIDENT
Name	:	STEVE HALL
Credential	:
Telephone Number	:	850-258-4428

Provider Enumeration Date	:	07/16/2010
Last Update Date	:	07/16/2010

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