MEDICARE: ADULT FAMILY HOME CARE, 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	311ZA0620X	Adult Care Home Facility	6905399	FL

General Provider Information

NPI Number	:	1871836908
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADULT FAMILY HOME CARE, INC.

Provider Business Mailing Address
First Line	:	2052-54 SYRACUSE COURT
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905
Country	:	US
Telephone Number	:	321-951-2887
Fax Number	:	321-327-5000

Provider Business Practice Location Address
First Line	:	2052 SYRACUSE CT NE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-3923
Country	:	US
Telephone Number	:	321-951-2887
Fax Number	:	321-327-5000

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	MS. BERNICE G LAIDLAW
Credential	:
Telephone Number	:	321-951-2887

Provider Enumeration Date	:	03/27/2013
Last Update Date	:	03/27/2013

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