=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588014047
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOMECARE ASSISTED LIVING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2016
-----------------------------------------------------
Last Update Date | 06/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1906 BELHAVEN DR
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32065-7663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-375-2672
-----------------------------------------------------
Fax | 904-375-2718
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1906 BELHAVEN DR
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32065-7663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-375-2672
-----------------------------------------------------
Fax | 904-375-2718
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | SATISH BADDAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-375-2672
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL12803
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------