MEDICARE: AJ'S TRANSITIONAL LIVING, LLC

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1679914816
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AJ'S TRANSITIONAL LIVING, LLC

Provider Business Mailing Address
First Line	:	11924 FOREST HILL BLVD
Second Line	:	SUITE 10A-193
City	:	WELLINGTON
State	:	FL
Zip	:	33414-6256
Country	:	US
Telephone Number	:	954-746-8232
Fax Number	:	954-746-8231

Provider Business Practice Location Address
First Line	:	7300 W LAKE DR
Second Line	:
City	:	LAKE CLARKE SHORES
State	:	FL
Zip	:	33406-6722
Country	:	US
Telephone Number	:	954-746-8232
Fax Number	:	954-746-8231

Authorized Official
Title or Position	:	BILLING DEPARTMENT
Name	:	THERESA SMITH
Credential	:
Telephone Number	:	954-746-8232

Provider Enumeration Date	:	07/16/2013
Last Update Date	:	07/07/2014

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