MEDICARE: ALF 8860 ADRD TRAINING PROVIDER LLC.

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	103TM1800X	Intellectual & Developmental Disabilities Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013572304
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALF 8860 ADRD TRAINING PROVIDER LLC.

Provider Business Mailing Address
First Line	:	7990 BAYMEADOWS RD E UNIT 1001
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-2977
Country	:	US
Telephone Number	:	904-379-7359
Fax Number	:	904-379-7359

Provider Business Practice Location Address
First Line	:	7990 BAYMEADOWS RD E UNIT 1001
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-2977
Country	:	US
Telephone Number	:	904-379-7359
Fax Number	:	904-379-7359

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MISS ERICA KAY EVANS
Credential	:
Telephone Number	:	904-379-7359

Provider Enumeration Date	:	05/02/2019
Last Update Date	:	05/02/2019

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