MEDICARE: BETHEL ASSISTED LIVING FACILITY, 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	AL12711	FL

General Provider Information

NPI Number	:	1881066363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BETHEL ASSISTED LIVING FACILITY, LLC

Provider Business Mailing Address
First Line	:	411 OCEANSIDE ST SW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32908-7127
Country	:	US
Telephone Number	:	321-821-7498
Fax Number	:	321-325-8040

Provider Business Practice Location Address
First Line	:	411 OCEANSIDE ST SW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32908-7127
Country	:	US
Telephone Number	:	321-821-7498
Fax Number	:	321-325-8040

Authorized Official
Title or Position	:	ADMINISTRATOR / OWNER
Name	:	MRS. JUNIA F OSIER
Credential	:
Telephone Number	:	321-961-1056

Provider Enumeration Date	:	10/23/2015
Last Update Date	:	10/23/2015

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