MEDICARE: FAMILY EXTENDED CARE OF PUNTA GORDA, 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	310400000X	Assisted Living Facility	AL5016	FL

General Provider Information

NPI Number	:	1851695399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY EXTENDED CARE OF PUNTA GORDA, INC

Provider Business Mailing Address
First Line	:	22332 VICK ST
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33980-2053
Country	:	US
Telephone Number	:	941-627-5388
Fax Number	:	941-627-2007

Provider Business Practice Location Address
First Line	:	22332 VICK ST
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33980-2053
Country	:	US
Telephone Number	:	941-627-5388
Fax Number	:	941-627-2007

Authorized Official
Title or Position	:	DIRECTOR OF QUALITY ASSURANCE
Name	:	DEBRA M LEWIS
Credential	:
Telephone Number	:	239-247-3248

Provider Enumeration Date	:	12/24/2010
Last Update Date	:	12/24/2010

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