=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578769493
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MALIBU LOVE AND CARE ASSISTED LIVING FACILITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6461 JOHNSON ST
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-7723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-894-6473
-----------------------------------------------------
Fax | 954-964-1213
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6461 JOHNSON ST
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-7723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-894-6473
-----------------------------------------------------
Fax | 954-964-1213
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. JANET SCOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-243-9815
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL10873
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------