MEDICARE: SOUTHERN BREEZE LIVING, 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	12111	FL

General Provider Information

NPI Number	:	1457773780
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN BREEZE LIVING, LLC

Provider Business Mailing Address
First Line	:	18 WOODWARD LN
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-3103
Country	:	US
Telephone Number	:	386-447-7405
Fax Number	:

Provider Business Practice Location Address
First Line	:	18 WOODWARD LN
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-3103
Country	:	US
Telephone Number	:	386-447-7405
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DENNIS DEAN
Credential	:
Telephone Number	:	386-447-7405

Provider Enumeration Date	:	01/06/2014
Last Update Date	:	01/06/2014

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