MEDICARE: ACACIA MILLS CNA

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	376K00000X	Nurse's Aide	CNA347186	FL
2	374U00000X	Home Health Aide	CNA347186	FL
3	251J00000X	Nursing Care Agency	CNA347186	FL

General Provider Information

NPI Number	:	1104318401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ACACIA MILLS CNA

Provider Business Mailing Address
First Line	:	114 SAND PINE TRL
Second Line	:
City	:	CRAWFORDVILLE
State	:	FL
Zip	:	32327-1253
Country	:	US
Telephone Number	:	850-933-8929
Fax Number	:

Provider Business Practice Location Address
First Line	:	15715 S DIXIE HWY STE 328
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33157-1883
Country	:	US
Telephone Number	:	786-592-1415
Fax Number	:	253-270-8779

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2018
Last Update Date	:	06/01/2018

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