MEDICARE: LA REINA ALF

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	AL-11480	FL

General Provider Information

NPI Number	:	1811138738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA REINA ALF

Provider Business Mailing Address
First Line	:	4501 NW 165TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33054-6005
Country	:	US
Telephone Number	:	786-282-7885
Fax Number	:

Provider Business Practice Location Address
First Line	:	4501 NW 165TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33054-6005
Country	:	US
Telephone Number	:	786-282-7885
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. OSNIEL VERA
Credential	:
Telephone Number	:	786-282-7885

Provider Enumeration Date	:	03/23/2009
Last Update Date	:	03/23/2009

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