MEDICARE: CALVINELLE ADULT HOME #2, 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	AL11635	FL

General Provider Information

NPI Number	:	1245585025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALVINELLE ADULT HOME #2, INC.

Provider Business Mailing Address
First Line	:	1786 NW 47TH TER
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33142-4071
Country	:	US
Telephone Number	:	305-640-8316
Fax Number	:	305-640-8316

Provider Business Practice Location Address
First Line	:	1786 NW 47TH TER
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33142-4071
Country	:	US
Telephone Number	:	305-640-8316
Fax Number	:	305-640-8316

Authorized Official
Title or Position	:	OWNER / ADMINISTRATOR
Name	:	GAYON DUNN
Credential	:
Telephone Number	:	305-308-2728

Provider Enumeration Date	:	07/18/2012
Last Update Date	:	07/18/2012

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