Healthcare Provider Details

I. General information

NPI: 1922856822
Provider Name (Legal Business Name): MIRA VIE AT GREEN KNOLL OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2024
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 ROUTE 202/206
BRIDGEWATER NJ
08807-1767
US

IV. Provider business mailing address

4301 ANCHOR PLAZA PKWY STE 300
TAMPA FL
33634-7521
US

V. Phone/Fax

Practice location:
  • Phone: 908-252-3400
  • Fax: 844-808-0071
Mailing address:
  • Phone: 813-330-2660
  • Fax: 844-808-0071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: BILLIE ABREU
Title or Position: DIRECTOR OF ADMIN
Credential:
Phone: 813-330-2660