=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114698255
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOKOMIS ASSISTED LIVING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2021
-----------------------------------------------------
Last Update Date | 09/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 336 MONET DR
-----------------------------------------------------
City | NOKOMIS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34275-1357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-401-7109
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1116 PIEDMONT AVE NE APT 6
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309-5010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-401-7109
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | KEVON BRUCE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 412-401-7109
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3104A0630X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 315D00000X
-----------------------------------------------------
Taxonomy Name | Inpatient Hospice
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------