MEDICARE: ENHANCED LIFESTYLE SENIOR HEALTHCARE 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902558406
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENHANCED LIFESTYLE SENIOR HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	2125 HARDEN BLVD
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33803-5918
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2125 HARDEN BLVD
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33803-5918
Country	:	US
Telephone Number	:	863-222-4060
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID GONZALEZ
Credential	:
Telephone Number	:	813-453-6179

Provider Enumeration Date	:	01/25/2022
Last Update Date	:	05/06/2022

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