MEDICARE: DIXIE OAK MANOR 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	AL8502	FL

General Provider Information

NPI Number	:	1124451687
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIXIE OAK MANOR LLC

Provider Business Mailing Address
First Line	:	6410 OLD DIXIE HWY
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32967-5909
Country	:	US
Telephone Number	:	772-564-6363
Fax Number	:

Provider Business Practice Location Address
First Line	:	6410 OLD DIXIE HWY
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32967-5909
Country	:	US
Telephone Number	:	772-564-6363
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	MR. SCOTT FUNNELL
Credential	:
Telephone Number	:	772-564-9393

Provider Enumeration Date	:	08/19/2013
Last Update Date	:	08/19/2013

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Directions to “DIXIE OAK MANOR LLC ” Practice Location

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