MEDICARE: MF HALIFAX, 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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1659607463
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MF HALIFAX, LLC

Provider Business Mailing Address
First Line	:	820 N CLYDE MORRIS BLVD
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32117-4594
Country	:	US
Telephone Number	:	386-274-4575
Fax Number	:

Provider Business Practice Location Address
First Line	:	820 N CLYDE MORRIS BLVD
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32117-4594
Country	:	US
Telephone Number	:	386-274-4575
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ERIC ROTH
Credential	:
Telephone Number	:	914-390-4377

Provider Enumeration Date	:	10/29/2009
Last Update Date	:	10/29/2009

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