MEDICARE: LORI VANDEKERCKHOVE

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

General Provider Information

NPI Number	:	1104787670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI VANDEKERCKHOVE

Provider Business Mailing Address
First Line	:	21807 PHILMONT CT
Second Line	:
City	:	BOCA RATON
State	:	FL
Zip	:	33428-4749
Country	:	US
Telephone Number	:	561-253-5649
Fax Number	:	561-253-5649

Provider Business Practice Location Address
First Line	:	3207 N MONROE ST
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32303-2832
Country	:	US
Telephone Number	:	850-562-4123
Fax Number	:	850-562-5895

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

Provider Enumeration Date	:	11/22/2025
Last Update Date	:	11/22/2025

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Directions to “ LORI VANDEKERCKHOVE ” Practice Location

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