MEDICARE: ACADEMY 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	310400000X	Assisted Living Facility	AL 7824	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	:	1326399833
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACADEMY ASSISTED LIVING FACILITY INC

Provider Business Mailing Address
First Line	:	1225 SOLTMAN AVE
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34950-6571
Country	:	US
Telephone Number	:	772-460-1211
Fax Number	:	772-460-7679

Provider Business Practice Location Address
First Line	:	1225 SOLTMAN AVE
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34950-6571
Country	:	US
Telephone Number	:	772-460-1211
Fax Number	:	772-460-7679

Authorized Official
Title or Position	:	ADMINASTRATOR
Name	:	MRS. RAJWANTIE LAL
Credential	:
Telephone Number	:	772-460-1211

Provider Enumeration Date	:	09/24/2012
Last Update Date	:	09/24/2012

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