=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326326869
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALTERNATIVE LIVING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2011
-----------------------------------------------------
Last Update Date | 08/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1053 JOHN SIMS PARKWAY
-----------------------------------------------------
City | NICEVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-833-9212
-----------------------------------------------------
Fax | 850-833-9389
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 207 HOSPITAL DRIVE
-----------------------------------------------------
City | FORT WALTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-833-9165
-----------------------------------------------------
Fax | 950-833-9389
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. RUTH R. LOVEJOY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-833-9165
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL5462
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------