MEDICARE: SANDRA CARES ADULT FAMILY CARE HOME, 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	311ZA0620X	Adult Care Home Facility	6906746	FL

General Provider Information

NPI Number	:	1447644653
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANDRA CARES ADULT FAMILY CARE HOME, INC.

Provider Business Mailing Address
First Line	:	4207 W WISCONSIN AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33616
Country	:	US
Telephone Number	:	813-506-3907
Fax Number	:	813-304-1869

Provider Business Practice Location Address
First Line	:	4207 W WISCONSIN AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33616-1139
Country	:	US
Telephone Number	:	813-506-3907
Fax Number	:	813-304-1869

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MARIE SANDRA JEANNOT
Credential	:	CNA
Telephone Number	:	813-506-3907

Provider Enumeration Date	:	03/25/2015
Last Update Date	:	03/25/2015

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