MEDICARE: THE MEADOWLANDS SENIOR LIVING 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	AL11961	FL

General Provider Information

NPI Number	:	1063781896
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE MEADOWLANDS SENIOR LIVING INC

Provider Business Mailing Address
First Line	:	126 SE ALAMO LN
Second Line	:
City	:	LEE
State	:	FL
Zip	:	32059-5708
Country	:	US
Telephone Number	:	850-971-5091
Fax Number	:	850-971-5091

Provider Business Practice Location Address
First Line	:	126 SE ALAMO LN
Second Line	:
City	:	LEE
State	:	FL
Zip	:	32059-5708
Country	:	US
Telephone Number	:	850-971-5091
Fax Number	:	850-971-5091

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. RONALD JAMES HERRING
Credential	:
Telephone Number	:	850-971-5091

Provider Enumeration Date	:	12/22/2011
Last Update Date	:	12/22/2011

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