MEDICARE: SUSIES HOME 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	AL12354	FL

General Provider Information

NPI Number	:	1700221959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSIES HOME LLC

Provider Business Mailing Address
First Line	:	28B KARAT PATH
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-5670
Country	:	US
Telephone Number	:	386-437-3131
Fax Number	:	386-437-3131

Provider Business Practice Location Address
First Line	:	28B KARAT PATH
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-5670
Country	:	US
Telephone Number	:	386-437-3131
Fax Number	:	386-437-3131

Authorized Official
Title or Position	:	CEO
Name	:	MR. JUNICHI OBAMA
Credential	:
Telephone Number	:	386-437-3131

Provider Enumeration Date	:	05/01/2013
Last Update Date	:	05/22/2013

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Directions to “SUSIES HOME LLC ” Practice Location

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