MEDICARE: OCEANSIDE LUXURY CARE, 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	207QA0505X	Adult Medicine Physician	ME46941	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ME46941	OTHER	FL	MEDICAL LICENSE NUMBER
2	44200	OTHER	FL	PROVIDER NUMBER

General Provider Information

NPI Number	:	1487794681
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCEANSIDE LUXURY CARE, LLC

Provider Business Mailing Address
First Line	:	2012 JACARANDA AVE
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34949-3326
Country	:	US
Telephone Number	:	772-216-1871
Fax Number	:

Provider Business Practice Location Address
First Line	:	2012 JACARANDA AVE
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34949-3326
Country	:	US
Telephone Number	:	772-216-1871
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JOHN R HAYES
Credential	:	MD
Telephone Number	:	772-216-1871

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	01/07/2008

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