MEDICARE: SELAH - FOREST LAKE 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	AL8869	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	:	1316281215
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SELAH - FOREST LAKE MANOR, LLC

Provider Business Mailing Address
First Line	:	252 FOREST LAKE BLVD
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32119-8106
Country	:	US
Telephone Number	:	386-760-7174
Fax Number	:	386-760-7812

Provider Business Practice Location Address
First Line	:	252 FOREST LAKE BLVD
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32119-8106
Country	:	US
Telephone Number	:	386-760-7174
Fax Number	:	386-760-7812

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. ALAN DANIEL PARRISH
Credential	:
Telephone Number	:	904-543-1818

Provider Enumeration Date	:	11/15/2012
Last Update Date	:	11/15/2012

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