Healthcare Provider Details

I. General information

NPI: 1598118812
Provider Name (Legal Business Name): 190 GOLDEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 NE 191ST ST
MIAMI FL
33179-3711
US

IV. Provider business mailing address

6511 NOVA DR STE 168
DAVIE FL
33317-7401
US

V. Phone/Fax

Practice location:
  • Phone: 305-651-9690
  • Fax:
Mailing address:
  • Phone: 813-956-8090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateFL

VIII. Authorized Official

Name: MARLINE C DUROSEAU
Title or Position: CFO
Credential: CFO
Phone: 954-367-4597