=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659630473
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE LONG LEARNING CENTER 2
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2012
-----------------------------------------------------
Last Update Date | 05/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 406 SE FALLON DR
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34983-2635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-237-2625
-----------------------------------------------------
Fax | 772-237-2624
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 406 SE FALLON DR
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34983-2635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-237-2625
-----------------------------------------------------
Fax | 772-237-2624
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. CHARLES HOWARD SWIHART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-237-2625
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311500000X
-----------------------------------------------------
Taxonomy Name | Alzheimer Center (Dementia Center)
-----------------------------------------------------
License Number | AL12123
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------