MEDICARE: 98

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	315P00000X	Intellectual Disabilities Intermediate Care Facility	CNA27905	FL
2	311ZA0620X	Adult Care Home Facility	CNA27905	FL

General Provider Information

NPI Number	:	1255658365
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	98

Provider Business Mailing Address
First Line	:	11314 MAHOPAC RD
Second Line	:
City	:	WEEKI WACHEE
State	:	FL
Zip	:	34614-3562
Country	:	US
Telephone Number	:	813-410-7719
Fax Number	:

Provider Business Practice Location Address
First Line	:	11314 MAHOPAC RD
Second Line	:
City	:	WEEKI WACHEE
State	:	FL
Zip	:	34614-3562
Country	:	US
Telephone Number	:	813-410-7719
Fax Number	:

Authorized Official
Title or Position	:	CNA
Name	:	MILO DFERIVAL
Credential	:	CNA
Telephone Number	:	813-410-7719

Provider Enumeration Date	:	04/28/2010
Last Update Date	:	04/28/2010

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