=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942669106
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTIAN LOVE AND TOUCH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2016
-----------------------------------------------------
Last Update Date | 02/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 165 CAROL SUSAN LN
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34982-8340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-206-5815
-----------------------------------------------------
Fax | 226-448-4409
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 165 CAROL SUSAN LN
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34982-8340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-206-5815
-----------------------------------------------------
Fax | 226-448-4409
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. ANDREA BROWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-206-5815
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 311ZA0620X
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------