Healthcare Provider Details

I. General information

NPI: 1366784589
Provider Name (Legal Business Name): PROFESSIONAL ADVANCED ADULT DAY CARE,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2668 SW 137TH AVE
MIAMI FL
33175-6314
US

IV. Provider business mailing address

2668 SW 137TH AVE
MIAMI FL
33175-6314
US

V. Phone/Fax

Practice location:
  • Phone: 305-456-9905
  • Fax: 305-846-9839
Mailing address:
  • Phone: 305-456-9905
  • Fax: 305-846-9839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number9206
License Number StateFL

VIII. Authorized Official

Name: MR. ERNESTO DOMINGUEZ
Title or Position: PRESIDENT
Credential: RN
Phone: 305-456-9905