=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558694844
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CR LOVING CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2009
-----------------------------------------------------
Last Update Date | 09/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 PEPPERDINE DR
-----------------------------------------------------
City | PALM COAST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32164-7497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-447-9152
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23 PEPPERDINE DR
-----------------------------------------------------
City | PALM COAST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32164-7497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-447-9152
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | MS. CATHLINE REID
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-447-9152
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL1035
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------