MEDICARE: SALEM VILLAGES MRDD, 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	315P00000X	Intellectual Disabilities Intermediate Care Facility

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	:	1386712875
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALEM VILLAGES MRDD, INC.

Provider Business Mailing Address
First Line	:	10140 LINN STATION RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-3813
Country	:	US
Telephone Number	:	800-866-0860
Fax Number	:

Provider Business Practice Location Address
First Line	:	325 N FREDERICK AVE
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-2909
Country	:	US
Telephone Number	:	352-372-0130
Fax Number	:

Authorized Official
Title or Position	:	PRIVACY OFFICER
Name	:	MS. DEENA OMBRES
Credential	:
Telephone Number	:	502-394-2387

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	10/27/2010

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