MEDICARE: EVELYN'S HOME ASSISTED LIVING 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	AL13064	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1396255139	OTHER		NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104313790
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVELYN'S HOME ASSISTED LIVING LLC

Provider Business Mailing Address
First Line	:	2119 BEACON LANDING CIR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32824-4374
Country	:	US
Telephone Number	:	407-497-1243
Fax Number	:	407-888-9121

Provider Business Practice Location Address
First Line	:	2119 BEACON LANDING CIR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32824-4374
Country	:	US
Telephone Number	:	407-497-1243
Fax Number	:	407-888-9121

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	FLORENCE WOBERAERE EJIOWHOR
Credential	:	RN
Telephone Number	:	407-497-1243

Provider Enumeration Date	:	04/18/2018
Last Update Date	:	06/16/2018

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