Healthcare Provider Details

I. General information

NPI: 1225268477
Provider Name (Legal Business Name): PALM VILLAGE ASSISTED LIVING, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2009
Last Update Date: 07/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7380 SW 48TH ST
MIAMI FL
33155-5523
US

IV. Provider business mailing address

7380 SW 48TH ST
MIAMI FL
33155-5523
US

V. Phone/Fax

Practice location:
  • Phone: 786-363-6880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: EDUARDO R LACASA
Title or Position: MANAGER
Credential:
Phone: 786-363-3880