MEDICARE: CORAL HOUSE ASSISTED LIVING COMMUNITY, 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1700253531
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORAL HOUSE ASSISTED LIVING COMMUNITY, LLC

Provider Business Mailing Address
First Line	:	26691 RICHMOND RD
Second Line	:
City	:	BEDFORD HEIGHTS
State	:	OH
Zip	:	44146-1421
Country	:	US
Telephone Number	:	216-292-5706
Fax Number	:	216-292-2273

Provider Business Practice Location Address
First Line	:	3501 HANCOCK BRIDGE PKWY
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33903-7095
Country	:	US
Telephone Number	:	239-454-1990
Fax Number	:	239-935-5908

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	WILLIAM I WEISBERG
Credential	:
Telephone Number	:	216-292-5706

Provider Enumeration Date	:	08/27/2015
Last Update Date	:	08/27/2015

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