=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972895720
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE OKEECHOBEE ALF, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2011
-----------------------------------------------------
Last Update Date | 05/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 STATE MARKET RD
-----------------------------------------------------
City | PAHOKEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33476-1542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-924-0010
-----------------------------------------------------
Fax | 561-924-0080
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 631 US HIGHWAY 1 SUITE #303
-----------------------------------------------------
City | NORTH PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33408-4617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-845-7767
-----------------------------------------------------
Fax | 561-828-7641
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MS. DEBORAH C PECK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-845-7767
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0630X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
-----------------------------------------------------
License Number | AL11952
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------