MEDICARE: EXCELSIOR OMEGA INC.

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	:	1801776661
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCELSIOR OMEGA INC.

Provider Business Mailing Address
First Line	:	15 DADE AVE
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34232-1608
Country	:	US
Telephone Number	:	941-371-4091
Fax Number	:	941-282-7673

Provider Business Practice Location Address
First Line	:	3548 SEA VIEW ST
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34239-3417
Country	:	US
Telephone Number	:	941-807-9657
Fax Number	:	941-282-7673

Authorized Official
Title or Position	:	MANAGER
Name	:	JACQUELINE DORELIEN
Credential	:
Telephone Number	:	941-807-9657

Provider Enumeration Date	:	09/03/2025
Last Update Date	:	10/23/2025

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