MEDICARE: LIFE LONG LEARNING CENTER 2

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)	AL12123	FL

General Provider Information

NPI Number	:	1659630473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE LONG LEARNING CENTER 2

Provider Business Mailing Address
First Line	:	406 SE FALLON DR
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983-2635
Country	:	US
Telephone Number	:	772-237-2625
Fax Number	:	772-237-2624

Provider Business Practice Location Address
First Line	:	406 SE FALLON DR
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983-2635
Country	:	US
Telephone Number	:	772-237-2625
Fax Number	:	772-237-2624

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. CHARLES HOWARD SWIHART
Credential	:
Telephone Number	:	772-237-2625

Provider Enumeration Date	:	05/14/2012
Last Update Date	:	05/14/2012

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