MEDICARE: LIFESTYLES 1 HEALTHCARE 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	314000000X	Skilled Nursing Facility	1614096	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	L4B	OTHER	FL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932173010
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESTYLES 1 HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	11300 110TH AVE
Second Line	:
City	:	SEMINOLE
State	:	FL
Zip	:	33778-3711
Country	:	US
Telephone Number	:	727-391-9986
Fax Number	:	727-456-5555

Provider Business Practice Location Address
First Line	:	11300 110TH AVE
Second Line	:
City	:	SEMINOLE
State	:	FL
Zip	:	33778-3711
Country	:	US
Telephone Number	:	727-391-9986
Fax Number	:	727-456-5555

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. WILLIAM C KELSEY
Credential	:
Telephone Number	:	727-391-9986

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	01/30/2008

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