=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023457306
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAFE AND SECURE RESPITE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2013
-----------------------------------------------------
Last Update Date | 06/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3215 E JAMES LEE BLVD
-----------------------------------------------------
City | CRESTVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32539-6037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-423-1228
-----------------------------------------------------
Fax | 850-423-1231
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3215 E JAMES LEE BLVD
-----------------------------------------------------
City | CRESTVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32539-6037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-423-1228
-----------------------------------------------------
Fax | 850-423-1231
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. SANDRA ANNE TINGLE
-----------------------------------------------------
Credential | MSW, MA
-----------------------------------------------------
Telephone | 850-423-1228
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311500000X
-----------------------------------------------------
Taxonomy Name | Alzheimer Center (Dementia Center)
-----------------------------------------------------
License Number | AL11068
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------