MEDICARE: AVENUE SUPPORTIVE CARE, 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	251B00000X	Case Management Agency
2	253Z00000X	In Home Supportive Care Agency	233310	FL
3	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1255757860
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVENUE SUPPORTIVE CARE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 26222
Second Line	:
City	:	TAMARAC
State	:	FL
Zip	:	33320-6222
Country	:	US
Telephone Number	:	954-716-6527
Fax Number	:

Provider Business Practice Location Address
First Line	:	5440 N STATE ROAD 7
Second Line	:	SUITE 208
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33319-2956
Country	:	US
Telephone Number	:	954-716-6527
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	GOLDIE LOZIER LOUIS
Credential	:
Telephone Number	:	954-716-6527

Provider Enumeration Date	:	03/07/2014
Last Update Date	:	03/07/2014

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