MEDICARE: MOORE CARE 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	AL12054	FL

General Provider Information

NPI Number	:	1417290636
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOORE CARE ASSISTED LIVING FACILITY

Provider Business Mailing Address
First Line	:	1291 W 32ND ST
Second Line	:
City	:	RIVIERA BEACH
State	:	FL
Zip	:	33404-3559
Country	:	US
Telephone Number	:	561-840-1627
Fax Number	:	561-840-1613

Provider Business Practice Location Address
First Line	:	1291 W 32ND ST
Second Line	:
City	:	RIVIERA BEACH
State	:	FL
Zip	:	33404-3559
Country	:	US
Telephone Number	:	561-840-1627
Fax Number	:	561-840-1613

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	KEISHA MONIQUE DOUGLAS-MOORE
Credential	:	L.P.N.
Telephone Number	:	561-603-1032

Provider Enumeration Date	:	04/05/2013
Last Update Date	:	04/05/2013

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