MEDICARE: MEADOW CARE ASSISTED LIVING FACILITY

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	12739	FL

General Provider Information

NPI Number	:	1023489044
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEADOW CARE ASSISTED LIVING FACILITY

Provider Business Mailing Address
First Line	:	686 SW LUCERO DR
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983-1894
Country	:	US
Telephone Number	:	772-237-5253
Fax Number	:

Provider Business Practice Location Address
First Line	:	686 SW LUCERO DR
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983-1894
Country	:	US
Telephone Number	:	772-237-5253
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	ALTHEA C WILMOT
Credential	:	MSN, RN
Telephone Number	:	561-707-0133

Provider Enumeration Date	:	10/16/2015
Last Update Date	:	10/16/2015

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