MEDICARE: INTIMATE CARE ASSISTED LIVING EXPERIENCE 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	:	1841070554
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTIMATE CARE ASSISTED LIVING EXPERIENCE LLC

Provider Business Mailing Address
First Line	:	15 STEPHANIE DR
Second Line	:
City	:	NEW MILFORD
State	:	CT
Zip	:	06776-2623
Country	:	US
Telephone Number	:	914-439-2205
Fax Number	:

Provider Business Practice Location Address
First Line	:	5327 NW CONLEY DR
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-4011
Country	:	US
Telephone Number	:	914-439-2205
Fax Number	:	860-799-6660

Authorized Official
Title or Position	:	OWNER
Name	:	ARLENE HALSTEAD
Credential	:	APRN
Telephone Number	:	914-439-2205

Provider Enumeration Date	:	10/02/2023
Last Update Date	:	10/02/2023

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