MEDICARE: SUNCOAST NEW OPTIONS FREDERICK AVENUE, 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	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	:	1528640166
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNCOAST NEW OPTIONS FREDERICK AVENUE, LLC

Provider Business Mailing Address
First Line	:	6531 MERIDIEN DR STE 103
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-3213
Country	:	US
Telephone Number	:
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	:	919-390-2980
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF BILLING
Name	:	MARY JOHNS BENSON
Credential	:
Telephone Number	:	336-553-5946

Provider Enumeration Date	:	04/23/2021
Last Update Date	:	04/23/2021

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