MEDICARE: CALVINELLE CARE CONCEPT, 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	3104A0625X	Assisted Living Facility (Mental Illness)	AL11635	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	:	1821338799
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALVINELLE CARE CONCEPT, LLC

Provider Business Mailing Address
First Line	:	6151 MIRAMAR PKWY
Second Line	:	SUITE 310
City	:	MIRAMAR
State	:	FL
Zip	:	33023-3970
Country	:	US
Telephone Number	:	305-308-2728
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	:	305-308-2728
Fax Number	:	305-640-8316

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. GAYON DIANA DUNN
Credential	:	RN
Telephone Number	:	305-308-2728

Provider Enumeration Date	:	02/28/2013
Last Update Date	:	03/10/2015

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