MEDICARE: BLUE ANGEL ENTERPRISES 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

General Provider Information

NPI Number	:	1174880785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE ANGEL ENTERPRISES INC

Provider Business Mailing Address
First Line	:	4814 N DARBY AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33603-2604
Country	:	US
Telephone Number	:	813-398-7086
Fax Number	:	813-333-1289

Provider Business Practice Location Address
First Line	:	4814 N DARBY AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33603-2604
Country	:	US
Telephone Number	:	813-398-7086
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ARMANDO AURELIO VAZQUEZ
Credential	:
Telephone Number	:	813-398-7086

Provider Enumeration Date	:	04/19/2012
Last Update Date	:	04/19/2012

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