Healthcare Provider Details

I. General information

NPI: 1598172256
Provider Name (Legal Business Name): HERNANDEZ ALF INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2507 W IDLEWILD AVE
TAMPA FL
33614-6107
US

IV. Provider business mailing address

2507 W IDLEWILD AVE
TAMPA FL
33614
US

V. Phone/Fax

Practice location:
  • Phone: 813-270-6040
  • Fax: 813-531-6824
Mailing address:
  • Phone: 813-270-6040
  • Fax: 813-531-6824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberAL11932
License Number StateFL

VIII. Authorized Official

Name: LISANDRA HERNANDEZ
Title or Position: OWNER
Credential:
Phone: 813-270-6040