MEDICARE: ROC MARIAN ASSISTED LIVING FACILITY, 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

General Provider Information

NPI Number	:	1760298921
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROC MARIAN ASSISTED LIVING FACILITY, LLC

Provider Business Mailing Address
First Line	:	244 SE VICTORIA GLN
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-9308
Country	:	US
Telephone Number	:	386-227-5519
Fax Number	:	386-361-2370

Provider Business Practice Location Address
First Line	:	233 SE COUNTRY CLUB RD
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-4986
Country	:	US
Telephone Number	:	386-227-5519
Fax Number	:	386-361-2370

Authorized Official
Title or Position	:	ADMIN/OWNER
Name	:	EMILY WEATHERSPOON
Credential	:
Telephone Number	:	386-227-5519

Provider Enumeration Date	:	12/03/2024
Last Update Date	:	12/03/2024

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