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General NPI Number Information
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NPI Number | 1063535854
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Entity Type | Organization
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Legal Business Name | COUNTRY CLUB LIVING , INC.
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Dates
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Enumeration Date | 04/09/2007
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Last Update Date | 01/27/2023
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Provider Practice Location Address
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Address Line | 16837 N. W. 91 CT.
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City | MIAMI LAKES
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State | FL
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Zip | 33018
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Country | US
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Telephone | 305-549-8657
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Fax | 305-816-9996
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Provider Business Mailing Address
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Address Line | 16837 N. W. 91 CT.
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City | MIAMI LAKES
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State | FL
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Zip | 33018
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Country | US
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Telephone | 305-549-8657
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Fax | 305-816-9996
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Authorized Official
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Title or Position | OWNER
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Name | YENEY SUAREZ I
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Credential |
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Telephone | 786-715-8902
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL10449
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License Number State | FL
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