MEDICARE: OCTAVIA GARDENS ASSISTED LIVING HOME

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	AL12183	FL

General Provider Information

NPI Number	:	1790123578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCTAVIA GARDENS ASSISTED LIVING HOME

Provider Business Mailing Address
First Line	:	5652 S RUE RD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33415-7148
Country	:	US
Telephone Number	:	561-305-3229
Fax Number	:

Provider Business Practice Location Address
First Line	:	5652 S RUE RD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33415-7148
Country	:	US
Telephone Number	:	561-305-3229
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. MONICA BARNES
Credential	:
Telephone Number	:	561-305-3229

Provider Enumeration Date	:	06/13/2013
Last Update Date	:	06/13/2013

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