MEDICARE: DIVINE LIVING ALF INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	12360	FL

General Provider Information

NPI Number	:	1003254053
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE LIVING ALF INC

Provider Business Mailing Address
First Line	:	4630 DECATUR CIR
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32934-7290
Country	:	US
Telephone Number	:	321-622-4615
Fax Number	:

Provider Business Practice Location Address
First Line	:	471 NEPTUNE DR NE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-1508
Country	:	US
Telephone Number	:	321-622-4615
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. NADJI D WILLIAMS
Credential	:
Telephone Number	:	321-622-4615

Provider Enumeration Date	:	06/12/2013
Last Update Date	:	06/12/2013

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Directions to “DIVINE LIVING ALF INC ” Practice Location

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