MEDICARE: ORANGE BLOSSOMS VILLA IV

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	AL12552	FL

General Provider Information

NPI Number	:	1548765019
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORANGE BLOSSOMS VILLA IV

Provider Business Mailing Address
First Line	:	121 MARTIN CIR
Second Line	:
City	:	ROYAL PALM BEACH
State	:	FL
Zip	:	33411-1708
Country	:	US
Telephone Number	:	561-762-1492
Fax Number	:	561-282-6892

Provider Business Practice Location Address
First Line	:	121 MARTIN CIR
Second Line	:
City	:	ROYAL PALM BEACH
State	:	FL
Zip	:	33411-1708
Country	:	US
Telephone Number	:	561-762-1492
Fax Number	:	561-282-6892

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. MARIA ANNA CUMMINGS
Credential	:
Telephone Number	:	561-762-1492

Provider Enumeration Date	:	03/27/2018
Last Update Date	:	03/27/2018

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