MEDICARE: CITRUS PINES ADULT FAMILY CARE, 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	311ZA0620X	Adult Care Home Facility	41679	FL

General Provider Information

NPI Number	:	1780131276
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITRUS PINES ADULT FAMILY CARE, LLC

Provider Business Mailing Address
First Line	:	5618 N LECANTO HWY
Second Line	:
City	:	BEVERLY HILLS
State	:	FL
Zip	:	34465
Country	:	US
Telephone Number	:	352-513-2024
Fax Number	:

Provider Business Practice Location Address
First Line	:	5618 N LECANTO HWY
Second Line	:
City	:	BEVERLY HILLS
State	:	FL
Zip	:	34465-2610
Country	:	US
Telephone Number	:	352-513-2024
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DANIEL G KERN
Credential	:
Telephone Number	:	352-513-2024

Provider Enumeration Date	:	09/01/2016
Last Update Date	:	09/01/2016

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