MEDICARE: HIDING PLACE ASSISTED LIVING FACILITY

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	AL11675	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	:	1356785992
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIDING PLACE ASSISTED LIVING FACILITY

Provider Business Mailing Address
First Line	:	1444 E 26TH ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-2505
Country	:	US
Telephone Number	:	904-608-1245
Fax Number	:

Provider Business Practice Location Address
First Line	:	1444 E 26TH ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-2505
Country	:	US
Telephone Number	:	904-608-1245
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. MARCIA JARRETT
Credential	:
Telephone Number	:	904-608-1245

Provider Enumeration Date	:	04/25/2013
Last Update Date	:	04/25/2013

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