MEDICARE: QUEEN ELAINE ASSISTED LIVING FACILITY, 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	310400000X	Assisted Living Facility	AL12973	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689114423
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUEEN ELAINE ASSISTED LIVING FACILITY, LLC

Provider Business Mailing Address
First Line	:	5840 RED BUG LAKE RD STE 495
Second Line	:
City	:	WINTER SPGS
State	:	FL
Zip	:	32708-5011
Country	:	US
Telephone Number	:	407-209-3242
Fax Number	:

Provider Business Practice Location Address
First Line	:	5840 RED BUG LAKE RD STE 495
Second Line	:
City	:	WINTER SPGS
State	:	FL
Zip	:	32708-5011
Country	:	US
Telephone Number	:	407-209-3242
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	LANA WATTS
Credential	:	R.N.,BSN
Telephone Number	:	407-209-3242

Provider Enumeration Date	:	02/27/2017
Last Update Date	:	02/27/2017

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