=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336543578
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANNE ASSISTED LIVING FACILITY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2014
-----------------------------------------------------
Last Update Date | 02/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1708 SW 11TH CT
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33312-3266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-332-4057
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1708 SW 11 CT
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CLERMELINE MARCELIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-332-4057
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------