=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114188430
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DE BLANCA HOME VI
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2008
-----------------------------------------------------
Last Update Date | 06/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 SW 103RD CT
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33174-1753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-228-0018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 SW 103RD CT
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33174-1753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-228-0018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BLANCA LOPETEGUI
-----------------------------------------------------
Credential | ADMINISTRATOR
-----------------------------------------------------
Telephone | 305-228-0018
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number | AL10171
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------