MEDICARE: NUESTRA CASA

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	11471	FL

General Provider Information

NPI Number	:	1659609014
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NUESTRA CASA

Provider Business Mailing Address
First Line	:	1906 N 'A' STREET
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33460
Country	:	US
Telephone Number	:	561-493-1785
Fax Number	:

Provider Business Practice Location Address
First Line	:	1906 N A ST
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33460-6002
Country	:	US
Telephone Number	:	561-493-1785
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	CONRADO BARRIO
Credential	:
Telephone Number	:	561-252-6399

Provider Enumeration Date	:	11/24/2009
Last Update Date	:	11/24/2009

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