Healthcare Provider Details

I. General information

NPI: 1679135032
Provider Name (Legal Business Name): BUENAVENTURA ASSISTED LIVING FACILITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 OAXACA LN
KISSIMMEE FL
34743-7019
US

IV. Provider business mailing address

140 OAXACA LN
KISSIMMEE FL
34743-7019
US

V. Phone/Fax

Practice location:
  • Phone: 407-350-5904
  • Fax: 407-641-8319
Mailing address:
  • Phone: 407-350-5904
  • Fax: 407-641-8319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MARIA RUIZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 407-350-5904