MEDICARE: ALMARK GROVE ASSISTED LIVING FACILITY, 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	385HR2065X	Child Physical Disabilities Respite Care	AL9874	FL

General Provider Information

NPI Number	:	1417407966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALMARK GROVE ASSISTED LIVING FACILITY, LLC

Provider Business Mailing Address
First Line	:	13920 EYLEWOOD DR
Second Line	:
City	:	WINTER GARDEN
State	:	FL
Zip	:	34787-4664
Country	:	US
Telephone Number	:	407-656-2443
Fax Number	:

Provider Business Practice Location Address
First Line	:	4502 ALMARK DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32839-1330
Country	:	US
Telephone Number	:	407-656-2443
Fax Number	:	407-654-0332

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. TEXUS WALLACE
Credential	:
Telephone Number	:	407-656-2443

Provider Enumeration Date	:	10/08/2016
Last Update Date	:	10/08/2016

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