MEDICARE: NORTHSTAR SENIOR LIVING, 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	311500000X	Alzheimer Center (Dementia Center)
2	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1619756483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSTAR SENIOR LIVING, INC.

Provider Business Mailing Address
First Line	:	3207 N MONROE ST
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32303-2832
Country	:	US
Telephone Number	:	850-562-4123
Fax Number	:

Provider Business Practice Location Address
First Line	:	3207 N MONROE ST
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32303-2832
Country	:	US
Telephone Number	:	850-562-4123
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF RISK MANAGEMENT
Name	:	TREVOR OGDEN
Credential	:
Telephone Number	:	530-242-8300

Provider Enumeration Date	:	09/21/2023
Last Update Date	:	09/21/2023

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