MEDICARE: SENIOR CARE LIVINGIV 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	311500000X	Alzheimer Center (Dementia Center)	AL12617	FL

General Provider Information

NPI Number	:	1972972099
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SENIOR CARE LIVINGIV LLC

Provider Business Mailing Address
First Line	:	350 MALABAR RD SW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-2947
Country	:	US
Telephone Number	:	321-574-6290
Fax Number	:

Provider Business Practice Location Address
First Line	:	350 MALABAR RD SW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-2947
Country	:	US
Telephone Number	:	321-574-6290
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. MARK C BOULDIN
Credential	:
Telephone Number	:	727-592-8889

Provider Enumeration Date	:	09/18/2015
Last Update Date	:	09/18/2015

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