MEDICARE: TAVARES VILLAGE RETIREMENT COMMUNITY, 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	AL8948	FL

General Provider Information

NPI Number	:	1730338179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAVARES VILLAGE RETIREMENT COMMUNITY, LLC

Provider Business Mailing Address
First Line	:	901 E WASHINGTON ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32801-2905
Country	:	US
Telephone Number	:	407-454-9096
Fax Number	:	407-843-0407

Provider Business Practice Location Address
First Line	:	1501 SUNSHINE PKWY
Second Line	:
City	:	TAVARES
State	:	FL
Zip	:	32778-4496
Country	:	US
Telephone Number	:	407-454-9096
Fax Number	:	407-843-0407

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. KENNETH NIELSON
Credential	:	MBA
Telephone Number	:	407-454-9096

Provider Enumeration Date	:	09/10/2008
Last Update Date	:	03/20/2013

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