MEDICARE: INFINITE CARE ASSISTED LIVING, LLC

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	1041C0700X	Clinical Social Worker	SW12345	FL
2	163W00000X	Registered Nurse	RN9327912	FL
3	174200000X	Meals Provider
4	177F00000X	Lodging Provider
5	251B00000X	Case Management Agency
6	251E00000X	Home Health Agency
7	251J00000X	Nursing Care Agency
8	347C00000X	Private Vehicle
9	363LF0000X	Family Nurse Practitioner	ARNP9319235	FL
10	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1508379140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INFINITE CARE ASSISTED LIVING, LLC

Provider Business Mailing Address
First Line	:	1023 NE 143RD ST
Second Line	:
City	:	NORTH MIAMI
State	:	FL
Zip	:	33161-2427
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	480 NW 123RD ST
Second Line	:
City	:	NORTH MIAMI
State	:	FL
Zip	:	33168-3545
Country	:	US
Telephone Number	:	202-779-8655
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	JUDINE TESSIER HITCHMON
Credential	:	LCSW
Telephone Number	:	202-779-8655

Provider Enumeration Date	:	11/06/2017
Last Update Date	:	11/06/2017

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