MEDICARE: LIFE TIME ALF CO

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	AL-11350	FL

General Provider Information

NPI Number	:	1225292022
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE TIME ALF CO

Provider Business Mailing Address
First Line	:	822 SW 89TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33174-3221
Country	:	US
Telephone Number	:	305-562-9069
Fax Number	:

Provider Business Practice Location Address
First Line	:	822 SW 89TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33174-3221
Country	:	US
Telephone Number	:	305-562-9069
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT-OWNER
Name	:	HENRY DIAZ
Credential	:
Telephone Number	:	305-562-9069

Provider Enumeration Date	:	07/11/2008
Last Update Date	:	07/11/2008

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