=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124451687
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIXIE OAK MANOR LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2013
-----------------------------------------------------
Last Update Date | 08/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6410 OLD DIXIE HWY
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32967-5909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-564-6363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6410 OLD DIXIE HWY
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32967-5909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-564-6363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | MR. SCOTT FUNNELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-564-9393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL8502
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------