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NPI Code Detail

MEDICARE: LL, FORT MYERS, LLC

MEDICARE: LL, FORT MYERS, 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
1310400000XAssisted Living FacilityAL5096FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1AL5096OTHERFLRESIDENTIAL CARE FACILITY LICENSE

General Provider Information

NPI Number : 1407270432
Entity Type Code : Organization
Provider Name (Legal Business Name) : LL, FORT MYERS, LLC
Provider Business Mailing Address
First Line : 7444 LONG AVE
Second Line :
City : SKOKIE
State : IL
Zip : 60077-3214
Country : US
Telephone Number : 847-329-4100
Fax Number : 847-329-4900
Provider Business Practice Location Address
First Line : 1896 PARK MEADOWS DR
Second Line :
City : FORT MYERS
State : FL
Zip : 33907-3738
Country : US
Telephone Number : 239-939-5421
Fax Number :
Authorized Official
Title or Position : COO
Name : BOBBY PETRAS
Credential :
Telephone Number : 260-797-9482
Provider Enumeration Date : 02/11/2014
Last Update Date : 02/11/2014

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