MEDICARE: GRACE MANOR RET 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	AL8445	FL

General Provider Information

NPI Number	:	1841457488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE MANOR RET INC

Provider Business Mailing Address
First Line	:	321 E HARVARD ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32804-5526
Country	:	US
Telephone Number	:	407-895-8418
Fax Number	:	407-895-8229

Provider Business Practice Location Address
First Line	:	321 E HARVARD ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32804-5526
Country	:	US
Telephone Number	:	407-895-8418
Fax Number	:	407-895-8229

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. HAFEEZ R ALI
Credential	:
Telephone Number	:	407-895-8418

Provider Enumeration Date	:	05/21/2008
Last Update Date	:	05/21/2008

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