MEDICARE: SEVENTY-SEVEN HOUSE

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	3104A0630X	Assisted Living Facility (Behavioral Disturbances)

General Provider Information

NPI Number	:	1356689822
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEVENTY-SEVEN HOUSE

Provider Business Mailing Address
First Line	:	183 JOG RD
Second Line	:
City	:	WEST PALM BCH
State	:	FL
Zip	:	33415-2343
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	183 JOG RD
Second Line	:
City	:	WEST PALM BCH
State	:	FL
Zip	:	33415-2343
Country	:	US
Telephone Number	:	561-373-8656
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	MR. PABLE LOPEZ DELEON
Credential	:
Telephone Number	:	561-373-8656

Provider Enumeration Date	:	01/17/2013
Last Update Date	:	01/17/2013

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Directions to “SEVENTY-SEVEN HOUSE ” Practice Location

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