MEDICARE: THE CHRISTIAN & MISSIONARY ALLIANCE FOUNDATION 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	AL6012	FL

General Provider Information

NPI Number	:	1386073088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CHRISTIAN & MISSIONARY ALLIANCE FOUNDATION INC

Provider Business Mailing Address
First Line	:	15000 SHELL POINT BLVD
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33908-1657
Country	:	US
Telephone Number	:	239-454-2175
Fax Number	:	239-454-2221

Provider Business Practice Location Address
First Line	:	3600 KINGS CROWN CT
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33908-1648
Country	:	US
Telephone Number	:	239-454-2179
Fax Number	:	239-454-2221

Authorized Official
Title or Position	:	DIRECTOR OF ASSISTED LIVING
Name	:	MRS. RITA MARIE SOUTHERN
Credential	:
Telephone Number	:	239-454-2179

Provider Enumeration Date	:	11/04/2013
Last Update Date	:	01/28/2020

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