MEDICARE: MATUSIK ADULT FAMILY CARE HOME

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	171M00000X	Case Manager/Care Coordinator	6906460	FL

General Provider Information

NPI Number	:	1407283666
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MATUSIK ADULT FAMILY CARE HOME

Provider Business Mailing Address
First Line	:	1580 PETERSON RD
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-8723
Country	:	US
Telephone Number	:	386-774-6493
Fax Number	:	386-774-6493

Provider Business Practice Location Address
First Line	:	1580 PETERSON RD
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-8723
Country	:	US
Telephone Number	:	386-774-6493
Fax Number	:	386-774-6493

Authorized Official
Title or Position	:	OWNER / OPERATOR
Name	:	MRS. DEBBIE HANSRAJDAI MATUSIK
Credential	:
Telephone Number	:	386-774-6493

Provider Enumeration Date	:	10/02/2013
Last Update Date	:	10/02/2013

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