Healthcare Provider Details

I. General information

NPI: 1669772588
Provider Name (Legal Business Name): BLACK CORAL GALLERY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2010
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16267 SW 88TH ST
MIAMI FL
33196-4912
US

IV. Provider business mailing address

16267 SW 88 ST
MIAMI FL
33196
US

V. Phone/Fax

Practice location:
  • Phone: 305-386-8356
  • Fax: 305-386-8357
Mailing address:
  • Phone: 305-386-8356
  • Fax: 305-386-8357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number9152
License Number StateFL

VIII. Authorized Official

Name: ALFREDO LOPEZ
Title or Position: OWNER
Credential:
Phone: 786-371-4697