MEDICARE: PETERSON 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	AL8638	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447697628
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETERSON ASSISTED LIVING FACILITY

Provider Business Mailing Address
First Line	:	1622 SILVER ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-4446
Country	:	US
Telephone Number	:	904-356-3022
Fax Number	:	904-350-9165

Provider Business Practice Location Address
First Line	:	1622 SILVER ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-4446
Country	:	US
Telephone Number	:	904-356-3022
Fax Number	:	904-350-9165

Authorized Official
Title or Position	:	DIRECTOR OF OPERATION
Name	:	MS. LAVERNE JACKSON
Credential	:
Telephone Number	:	904-356-3922

Provider Enumeration Date	:	05/29/2013
Last Update Date	:	05/29/2013

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