MEDICARE: SHADY OAKS LIVING CENTER

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	3104A0625X	Assisted Living Facility (Mental Illness)	AL 8450	FL
2	310400000X	Assisted Living Facility	AL 8450	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	:	1699076703
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHADY OAKS LIVING CENTER

Provider Business Mailing Address
First Line	:	PO BOX 280339
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33682-0339
Country	:	US
Telephone Number	:	813-978-0819
Fax Number	:	813-425-6925

Provider Business Practice Location Address
First Line	:	2208 E 138TH AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33613-4435
Country	:	US
Telephone Number	:	813-978-0819
Fax Number	:	813-425-6925

Authorized Official
Title or Position	:	PRESIDENT/ADMINISTRATOR
Name	:	MR. JOSEPH WILFRED JOSEPH
Credential	:
Telephone Number	:	813-978-0819

Provider Enumeration Date	:	11/04/2010
Last Update Date	:	11/04/2010

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Directions to “SHADY OAKS LIVING CENTER ” Practice Location

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