MEDICARE: CHRISTALLIS MANOR II 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	310400000X	Assisted Living 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	:	1528686672
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRISTALLIS MANOR II LLC

Provider Business Mailing Address
First Line	:	819 N 31ST CT
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-6111
Country	:	US
Telephone Number	:	954-274-5573
Fax Number	:

Provider Business Practice Location Address
First Line	:	819 N 31ST CT
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-6111
Country	:	US
Telephone Number	:	954-274-5573
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	AMPARO M DIERKING
Credential	:
Telephone Number	:	954-274-5573

Provider Enumeration Date	:	07/06/2020
Last Update Date	:	10/01/2021

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Directions to “CHRISTALLIS MANOR II LLC ” Practice Location

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