=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417556028
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 5081 CAMBRIDGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2020
-----------------------------------------------------
Last Update Date | 10/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5081 NW DUNN RD
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34981-4942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-990-8089
-----------------------------------------------------
Fax | 561-584-7505
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4285 NW 66TH PL
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33496-4029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-990-8089
-----------------------------------------------------
Fax | 561-584-7505
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MRS. CLAUDIA A MARINOFF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-990-8089
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------