MEDICARE: VAN-LEIGH OF VERO BEACH, 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	AL9844	FL

General Provider Information

NPI Number	:	1952749053
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VAN-LEIGH OF VERO BEACH, LLC

Provider Business Mailing Address
First Line	:	615 IRIS LN
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32963-1859
Country	:	US
Telephone Number	:	772-794-1277
Fax Number	:	772-794-2488

Provider Business Practice Location Address
First Line	:	1934 22ND AVE
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-3084
Country	:	US
Telephone Number	:	772-794-1277
Fax Number	:	772-794-2488

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	MR. MARVIN JAMES VAN BENSCHOTEN
Credential	:
Telephone Number	:	772-794-1277

Provider Enumeration Date	:	06/11/2013
Last Update Date	:	06/11/2013

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