MEDICARE: GREEN LIFE ASSISTED LIVING FACILITY, 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	AL12577	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	:	1124423470
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN LIFE ASSISTED LIVING FACILITY, LLC

Provider Business Mailing Address
First Line	:	840 SW 8TH ST
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33060-8214
Country	:	US
Telephone Number	:	855-331-6615
Fax Number	:	855-638-4902

Provider Business Practice Location Address
First Line	:	840 SW 8TH ST
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33060-8214
Country	:	US
Telephone Number	:	855-331-6615
Fax Number	:	855-638-4902

Authorized Official
Title or Position	:	CEO
Name	:	MS. MARI CLARK
Credential	:
Telephone Number	:	813-931-1433

Provider Enumeration Date	:	10/29/2014
Last Update Date	:	03/05/2015

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