MEDICARE: MOTT FOSTER HOME (ALF)

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)	AL5053	FL

General Provider Information

NPI Number	:	1720409436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOTT FOSTER HOME (ALF)

Provider Business Mailing Address
First Line	:	1746 S WASHINGTON AVE
Second Line	:
City	:	APOPKA
State	:	FL
Zip	:	32703-7518
Country	:	US
Telephone Number	:	407-886-7005
Fax Number	:	407-886-7005

Provider Business Practice Location Address
First Line	:	1746 S WASHINGTON AVE
Second Line	:
City	:	APOPKA
State	:	FL
Zip	:	32703-7518
Country	:	US
Telephone Number	:	407-886-7005
Fax Number	:	407-886-7005

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. MARY ALICA MOTT
Credential	:
Telephone Number	:	407-886-7005

Provider Enumeration Date	:	12/23/2013
Last Update Date	:	12/23/2013

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1487113965 — LAUREN ELIZABETH DELVECCHIO
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Directions to “MOTT FOSTER HOME (ALF) ” Practice Location

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