MEDICARE: J & K ASSISTED LIVING II

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	:	1609698315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J & K ASSISTED LIVING II

Provider Business Mailing Address
First Line	:	256 BARBAROSSA RD NW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-1809
Country	:	US
Telephone Number	:	321-704-0053
Fax Number	:	321-345-4297

Provider Business Practice Location Address
First Line	:	256 BARBAROSSA RD NW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-1809
Country	:	US
Telephone Number	:	321-704-0053
Fax Number	:	321-345-4297

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	KETLIE ELIE
Credential	:	ADMINISTRATOR
Telephone Number	:	321-704-0053

Provider Enumeration Date	:	10/25/2024
Last Update Date	:	10/25/2024

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