MEDICARE: WILNIQUE PEACEFUL ADULT FAMILY CARE HOME

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	311ZA0620X	Adult Care Home Facility	6906735	FL

General Provider Information

NPI Number	:	1467843110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILNIQUE PEACEFUL ADULT FAMILY CARE HOME

Provider Business Mailing Address
First Line	:	4435 SW MASEFIELD ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-6867
Country	:	US
Telephone Number	:	954-934-5852
Fax Number	:

Provider Business Practice Location Address
First Line	:	4435 SW MASEFIELD ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-6867
Country	:	US
Telephone Number	:	954-934-5852
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. WILNIQUE TURENNE
Credential	:
Telephone Number	:	954-934-5852

Provider Enumeration Date	:	02/16/2015
Last Update Date	:	02/16/2015

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