=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972972099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SENIOR CARE LIVINGIV LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2015
-----------------------------------------------------
Last Update Date | 09/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 MALABAR RD SW
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32907-2947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-574-6290
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 MALABAR RD SW
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32907-2947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-574-6290
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. MARK C BOULDIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-592-8889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311500000X
-----------------------------------------------------
Taxonomy Name | Alzheimer Center (Dementia Center)
-----------------------------------------------------
License Number | AL12617
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------