MEDICARE: BRANDYWYNE 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	310400000X	Assisted Living Facility

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	:	1477060754
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRANDYWYNE ASSISTED LIVING FACILITY, LLC.

Provider Business Mailing Address
First Line	:	1908 E 131ST AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33612-4690
Country	:	US
Telephone Number	:	813-293-9981
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 LAKE MARIAM DR
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-0927
Country	:	US
Telephone Number	:	813-293-9981
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	KHALID SAKR
Credential	:
Telephone Number	:	727-439-5363

Provider Enumeration Date	:	01/08/2018
Last Update Date	:	01/08/2018

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