MEDICARE: LAKE ALFRED ASSISTED LIVING AND RETIREMENT HOME, INC.

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	AL10511	FL

General Provider Information

NPI Number	:	1598943607
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE ALFRED ASSISTED LIVING AND RETIREMENT HOME, INC.

Provider Business Mailing Address
First Line	:	350 W HAINES BLVD
Second Line	:
City	:	LAKE ALFRED
State	:	FL
Zip	:	33850-2718
Country	:	US
Telephone Number	:	863-956-8831
Fax Number	:	863-956-9141

Provider Business Practice Location Address
First Line	:	3101 ARCHER AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32833-4365
Country	:	US
Telephone Number	:	407-963-8777
Fax Number	:	407-568-5999

Authorized Official
Title or Position	:	PRESIDENT/ADMINISTRATOR
Name	:	MR. ARNULFO SALGADO SIMONDAC
Credential	:
Telephone Number	:	863-956-8831

Provider Enumeration Date	:	01/31/2008
Last Update Date	:	01/31/2008

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