=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982946042
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATH OF LIFE ASSISTED LIVING OF PALM BEACH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2013
-----------------------------------------------------
Last Update Date | 03/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5800 GUN CLUB RD
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33415-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-855-6143
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5800 GUN CLUB RD
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33415-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JESSICA HERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-282-2620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL12319
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------