=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417290636
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOORE CARE ASSISTED LIVING FACILITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2013
-----------------------------------------------------
Last Update Date | 04/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1291 W 32ND ST
-----------------------------------------------------
City | RIVIERA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33404-3559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-840-1627
-----------------------------------------------------
Fax | 561-840-1613
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1291 W 32ND ST
-----------------------------------------------------
City | RIVIERA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33404-3559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-840-1627
-----------------------------------------------------
Fax | 561-840-1613
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | KEISHA MONIQUE DOUGLAS-MOORE
-----------------------------------------------------
Credential | L.P.N.
-----------------------------------------------------
Telephone | 561-603-1032
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL12054
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------