=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720409436
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOTT FOSTER HOME (ALF)
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2013
-----------------------------------------------------
Last Update Date | 12/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1746 S WASHINGTON AVE
-----------------------------------------------------
City | APOPKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32703-7518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-886-7005
-----------------------------------------------------
Fax | 407-886-7005
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1746 S WASHINGTON AVE
-----------------------------------------------------
City | APOPKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32703-7518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-886-7005
-----------------------------------------------------
Fax | 407-886-7005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. MARY ALICA MOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-886-7005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number | AL5053
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------