MEDICARE: ST. MARY'S HOME ASSISTED LIVING FACILITY

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	302R00000X	Health Maintenance Organization	AL4860	FL

General Provider Information

NPI Number	:	1558769943
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. MARY'S HOME ASSISTED LIVING FACILITY

Provider Business Mailing Address
First Line	:	718 W WINTER PARK ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32804-4902
Country	:	US
Telephone Number	:	407-843-0951
Fax Number	:

Provider Business Practice Location Address
First Line	:	718 W WINTER PARK ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32804-4902
Country	:	US
Telephone Number	:	407-843-0951
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. JAMES LAYUGAN BATTUNG
Credential	:
Telephone Number	:	407-843-0951

Provider Enumeration Date	:	12/17/2014
Last Update Date	:	12/18/2014

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