MEDICARE: THE PERFECT PLACE ALF 3

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	AL12722	FL

General Provider Information

NPI Number	:	1679941777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE PERFECT PLACE ALF 3

Provider Business Mailing Address
First Line	:	1517 SW BELLEVUE AVE
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-1102
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1517 SW BELLEVUE AVE
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-1102
Country	:	US
Telephone Number	:	786-307-6994
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	IRAN VEJERANO
Credential	:
Telephone Number	:	786-307-6994

Provider Enumeration Date	:	09/04/2015
Last Update Date	:	09/04/2015

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