MEDICARE: A PLACE LIKE HOME, ALF

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	11499	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	:	1144563016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A PLACE LIKE HOME, ALF

Provider Business Mailing Address
First Line	:	6655 S US HIGHWAY 1
Second Line	:
City	:	GRANT
State	:	FL
Zip	:	32949-2221
Country	:	US
Telephone Number	:	321-693-3325
Fax Number	:	321-956-7571

Provider Business Practice Location Address
First Line	:	1971 PORT MALABAR BLVD NE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-5436
Country	:	US
Telephone Number	:	321-693-3325
Fax Number	:	321-821-5327

Authorized Official
Title or Position	:	ADMINISTRATOR/OWNER
Name	:	DR. DIANE MARIE WALKER
Credential	:	PSY.D.
Telephone Number	:	321-693-3325

Provider Enumeration Date	:	03/29/2013
Last Update Date	:	03/29/2013

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Directions to “A PLACE LIKE HOME, ALF ” Practice Location

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