=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003119686
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | I & G ASSISTED LIVING FACILITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2010
-----------------------------------------------------
Last Update Date | 12/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6560 HARBOUR RD
-----------------------------------------------------
City | NORTH LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33068-3838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-234-4357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6560 HARBOUR RD
-----------------------------------------------------
City | NORTH LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33068-3838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-234-4357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | IMOGENE JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 754-234-4357
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL11032
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------