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General NPI Number Information
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NPI Number | 1679914741
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Entity Type | Organization
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Legal Business Name | INDEPENDENT LIVING WITH CARE, INC. ALF
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Dates
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Enumeration Date | 07/17/2013
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Last Update Date | 07/17/2013
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Provider Practice Location Address
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Address Line | 3165 SW FAMBROUGH ST
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City | PORT ST LUCIE
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State | FL
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Zip | 34953-4541
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Country | US
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Telephone | 772-878-1010
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Fax | 772-345-1402
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Provider Business Mailing Address
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Address Line | 3165 SW FAMBROUGH ST
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City | PORT ST LUCIE
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State | FL
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Zip | 34953-4541
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Country | US
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Telephone | 772-878-1010
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Fax | 772-345-1402
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Authorized Official
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Title or Position | OWNER
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Name | TISA FORTE
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Credential |
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Telephone | 772-878-1010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 11368
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License Number State | FL
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