=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447789730
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SALEYMA HEALTH MED WAIVER SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1302 SW PAAR DR
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34953-6155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-888-1371
-----------------------------------------------------
Fax | 772-408-0574
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1302 SW PAAR DR
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34953-6155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-888-1371
-----------------------------------------------------
Fax | 772-408-0574
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | MR. FRITZ MASSON ALEXANDRE
-----------------------------------------------------
Credential | RMA, MPH
-----------------------------------------------------
Telephone | 321-888-1371
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------