MEDICARE: CARLTON SHORES NH 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	6110	FL
2	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)
3	314000000X	Skilled Nursing Facility	002213800	FL

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	:	1588986368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARLTON SHORES NH LLC

Provider Business Mailing Address
First Line	:	1350 S NOVA RD
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-5812
Country	:	US
Telephone Number	:	386-258-5544
Fax Number	:	386-255-5623

Provider Business Practice Location Address
First Line	:	1350 S NOVA RD
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-5812
Country	:	US
Telephone Number	:	386-258-5544
Fax Number	:	386-255-5623

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

Provider Enumeration Date	:	02/22/2010
Last Update Date	:	06/20/2011

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Directions to “CARLTON SHORES NH LLC ” Practice Location

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