MEDICARE: ADULT LIFE CARE CENTER 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	261QA0600X	Adult Day Care Clinic/Center	1443	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1443	OTHER	MO	ADULT DAY CARE LICENSE NUMBER

General Provider Information

NPI Number	:	1396263075
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADULT LIFE CARE CENTER LLC

Provider Business Mailing Address
First Line	:	8607 MAPLE AVE
Second Line	:
City	:	RAYTOWN
State	:	MO
Zip	:	64138-3358
Country	:	US
Telephone Number	:	816-266-3057
Fax Number	:

Provider Business Practice Location Address
First Line	:	11517 HICKMAN MILLS DR # AB
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64134-4210
Country	:	US
Telephone Number	:	816-844-9374
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	SHANTIC BANDY
Credential	:
Telephone Number	:	816-266-3057

Provider Enumeration Date	:	09/01/2017
Last Update Date	:	09/01/2017

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