MEDICARE: MAJESTIC CARE MARINA MILE 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	9568	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9568	OTHER	FL	LICENCE

General Provider Information

NPI Number	:	1407220163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAJESTIC CARE MARINA MILE LLC

Provider Business Mailing Address
First Line	:	7200 W CAMINO REAL
Second Line	:
City	:	BOCA RATON
State	:	FL
Zip	:	33433-5511
Country	:	US
Telephone Number	:	954-266-4015
Fax Number	:

Provider Business Practice Location Address
First Line	:	1320 SW 26TH ST
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33315-2346
Country	:	US
Telephone Number	:	954-266-4015
Fax Number	:

Authorized Official
Title or Position	:	ACCOUNTING ADMINISTRATOR
Name	:	ISRAELA HERSKOVITZ
Credential	:
Telephone Number	:	954-266-4015

Provider Enumeration Date	:	11/18/2015
Last Update Date	:	11/18/2015

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