MEDICARE: BLUE FOUNTAIN HOME CARE, 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	310400000X	Assisted Living Facility	AL11411	FL

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	:	1073910840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE FOUNTAIN HOME CARE, LLC

Provider Business Mailing Address
First Line	:	2440 EMERSON DR SE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32909-4972
Country	:	US
Telephone Number	:	321-327-8762
Fax Number	:	321-914-4069

Provider Business Practice Location Address
First Line	:	2440 EMERSON DR SE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32909-4972
Country	:	US
Telephone Number	:	321-327-8762
Fax Number	:	321-914-4069

Authorized Official
Title or Position	:	ADMINISTRATOR/OWNER
Name	:	MAGDAD DELINOIS
Credential	:
Telephone Number	:	954-559-3265

Provider Enumeration Date	:	11/21/2014
Last Update Date	:	11/21/2014

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Directions to “BLUE FOUNTAIN HOME CARE, LLC ” Practice Location

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