MEDICARE: MIAMI GARDENS MANOR, 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	AL11092	FL

General Provider Information

NPI Number	:	1922305200
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIAMI GARDENS MANOR, INC.

Provider Business Mailing Address
First Line	:	915 NW 175TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33169-4613
Country	:	US
Telephone Number	:	954-815-8171
Fax Number	:

Provider Business Practice Location Address
First Line	:	915 NW 175TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33169-4613
Country	:	US
Telephone Number	:	954-815-8171
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	NOVELETTE BEHARIE- THOMAS
Credential	:
Telephone Number	:	954-815-8171

Provider Enumeration Date	:	02/22/2011
Last Update Date	:	02/22/2011

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