MEDICARE: RESTHAVEN OF HARDEE COUNTY INC

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	AL5073	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700020914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESTHAVEN OF HARDEE COUNTY INC

Provider Business Mailing Address
First Line	:	120 N 4TH AVE
Second Line	:
City	:	WAUCHULA
State	:	FL
Zip	:	33873-2710
Country	:	US
Telephone Number	:	863-773-2637
Fax Number	:

Provider Business Practice Location Address
First Line	:	298 RESTHAVEN RD
Second Line	:
City	:	ZOLFO SPRINGS
State	:	FL
Zip	:	33890-9500
Country	:	US
Telephone Number	:	863-773-6000
Fax Number	:

Authorized Official
Title or Position	:	CHAIRMAN BOARD OF DIRECTORS
Name	:	MARY LOIS CRAWLEY
Credential	:
Telephone Number	:	863-773-6000

Provider Enumeration Date	:	05/01/2009
Last Update Date	:	05/01/2009

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