=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306151071
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIAZ HOME CARE ALF II, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2010
-----------------------------------------------------
Last Update Date | 07/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12211 SW 268 STREET
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33032-7949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-286-2826
-----------------------------------------------------
Fax | 786-601-7751
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12211 SW 268 STREET
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33032-7949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-286-2826
-----------------------------------------------------
Fax | 786-601-7751
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JORGE GONGAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-282-6305
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL11715
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 11715
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------