MEDICARE: CRESCENT CARE CORPORATION DBA APPLE HOUSE 11

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	AL9265	FL

General Provider Information

NPI Number	:	1942690110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRESCENT CARE CORPORATION DBA APPLE HOUSE 11

Provider Business Mailing Address
First Line	:	2301 S US HIGHWAY 17
Second Line	:
City	:	CRESCENT CITY
State	:	FL
Zip	:	32112-3933
Country	:	US
Telephone Number	:	386-698-1444
Fax Number	:

Provider Business Practice Location Address
First Line	:	2301 S US HIGHWAY 17
Second Line	:
City	:	CRESCENT CITY
State	:	FL
Zip	:	32112-3933
Country	:	US
Telephone Number	:	386-698-1444
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MISS MARIA MONTEBON
Credential	:
Telephone Number	:	386-698-1444

Provider Enumeration Date	:	01/27/2015
Last Update Date	:	01/27/2015

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