MEDICARE: SALEM HOMES OF FLORIDA, INC.

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	4097095	FL

General Provider Information

NPI Number	:	1629404819
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALEM HOMES OF FLORIDA, INC.

Provider Business Mailing Address
First Line	:	9901 LINN STATION RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-3808
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4748 TUNIS ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32205-7379
Country	:	US
Telephone Number	:	352-372-0310
Fax Number	:

Authorized Official
Title or Position	:	ASSOC. GEN. COUNSEL/PRIVACY OFFICER
Name	:	MS. DEENA G. OMBRES
Credential	:
Telephone Number	:	502-394-2100

Provider Enumeration Date	:	09/19/2013
Last Update Date	:	09/19/2013

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