MEDICARE: HIDDEN RANCHES ASSISTED LIVING, 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	310400000X	Assisted Living Facility	AL8744	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164858262
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIDDEN RANCHES ASSISTED LIVING, INC

Provider Business Mailing Address
First Line	:	1864 NW 175TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33056-4840
Country	:	US
Telephone Number	:	305-624-4901
Fax Number	:

Provider Business Practice Location Address
First Line	:	1864 NW 175TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33056-4840
Country	:	US
Telephone Number	:	305-624-4901
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	RICKI KANETI
Credential	:
Telephone Number	:	305-624-4901

Provider Enumeration Date	:	09/20/2013
Last Update Date	:	09/20/2013

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