MEDICARE: ROYALTY RENOVATIONS INC DBA

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	261QD1600X	Developmental Disabilities Clinic/Center

General Provider Information

NPI Number	:	1538348883
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROYALTY RENOVATIONS INC DBA

Provider Business Mailing Address
First Line	:	1521 AVONDALE RIDGE DR
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33567-3684
Country	:	US
Telephone Number	:	823-909-3710
Fax Number	:

Provider Business Practice Location Address
First Line	:	6803 S HIMES AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33611-5129
Country	:	US
Telephone Number	:	813-909-3710
Fax Number	:

Authorized Official
Title or Position	:	MEDICAID WAIVER PROVIDER-ADMINISTRA
Name	:	DANE MCCAL JONES
Credential	:
Telephone Number	:	813-909-3710

Provider Enumeration Date	:	11/02/2007
Last Update Date	:	11/02/2007

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