MEDICARE: SHAN GROUP 4 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	253Z00000X	In Home Supportive Care Agency
2	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1356156186
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHAN GROUP 4 LLC

Provider Business Mailing Address
First Line	:	15251 NE 18TH AVE STE 9
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33162-6039
Country	:	US
Telephone Number	:	305-627-3103
Fax Number	:

Provider Business Practice Location Address
First Line	:	621 NW 53RD ST 125
Second Line	:	OFFICE18
City	:	BOCA RATON
State	:	FL
Zip	:	33487-8235
Country	:	US
Telephone Number	:	561-677-3133
Fax Number	:	561-879-4025

Authorized Official
Title or Position	:	CEO
Name	:	ALI MANDSOURWALA
Credential	:
Telephone Number	:	561-677-3133

Provider Enumeration Date	:	02/10/2025
Last Update Date	:	02/10/2025

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