MEDICARE: LISE'S GARDEN AFCH, 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	311ZA0620X	Adult Care Home Facility	6906849	FL

General Provider Information

NPI Number	:	1639678139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISE'S GARDEN AFCH, LLC

Provider Business Mailing Address
First Line	:	1542 PROVIDENCE CIR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32818-5708
Country	:	US
Telephone Number	:	407-668-4654
Fax Number	:

Provider Business Practice Location Address
First Line	:	1542 PROVIDENCE CIR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32818-5708
Country	:	US
Telephone Number	:	407-668-4654
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	LISE I HYPPOLITE-ALPHONSE
Credential	:
Telephone Number	:	321-948-8533

Provider Enumeration Date	:	02/09/2018
Last Update Date	:	02/09/2018

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