=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548500572
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARDEN MANOR INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2013
-----------------------------------------------------
Last Update Date | 02/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1562 GARDEN AVE
-----------------------------------------------------
City | HOLLY HILL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32117-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-677-0402
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1562 GARDEN AVE
-----------------------------------------------------
City | HOLLY HILL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32117-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-677-0402
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | MR. TRAVIS N RAMASAMI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-677-0402
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number | AL11547
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------