MEDICARE: PRICILLA'S LOVING CARE CORP

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

General Provider Information

NPI Number	:	1538311303
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRICILLA'S LOVING CARE CORP

Provider Business Mailing Address
First Line	:	7273 NW 80TH CT
Second Line	:
City	:	OKEECHOBEE
State	:	FL
Zip	:	34972-7802
Country	:	US
Telephone Number	:	772-370-7251
Fax Number	:	772-879-6737

Provider Business Practice Location Address
First Line	:	213 SW LANGFIELD AVE
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34984-4926
Country	:	US
Telephone Number	:	772-370-7251
Fax Number	:	772-879-6737

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. YAMARIS TATUM
Credential	:
Telephone Number	:	772-370-7251

Provider Enumeration Date	:	10/10/2008
Last Update Date	:	10/10/2008

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