=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558773325
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ZION'S II ASSISTED LIVING FACILITY,INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2014
-----------------------------------------------------
Last Update Date | 05/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 256 BARBAROSSA RD NW
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32907-1809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-693-0282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 256 BARBAROSSA RD NW
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32907-1809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-693-0282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | SHERON WHYNE-KELLY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-693-0282
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 11317
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------