=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083113070
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FABULOUS RESORT ASSISTED LIVING FACILITATOR LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2018
-----------------------------------------------------
Last Update Date | 02/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1762 SE CARVALHO ST
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34983-4554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-541-2089
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1762 SE CARVALHO ST
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34983-4554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-541-2089
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | FABIOLA ALEXANDRE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-541-2089
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL13125
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------