MEDICARE: HIDDEN PALMS ALF, 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	AL8749	FL

General Provider Information

NPI Number	:	1508062027
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIDDEN PALMS ALF, LLC

Provider Business Mailing Address
First Line	:	2675 N ANDREWS AVE
Second Line	:
City	:	WILTON MANORS
State	:	FL
Zip	:	33311-2509
Country	:	US
Telephone Number	:	954-563-2288
Fax Number	:

Provider Business Practice Location Address
First Line	:	2675 N ANDREWS AVE
Second Line	:
City	:	WILTON MANORS
State	:	FL
Zip	:	33311-2509
Country	:	US
Telephone Number	:	954-563-2288
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MR. WILLIAM MANDO
Credential	:
Telephone Number	:	813-635-9500

Provider Enumeration Date	:	06/22/2007
Last Update Date	:	08/22/2020

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