=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326546359
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIVE STAR ASSISTED LIVING FACILITY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2018
-----------------------------------------------------
Last Update Date | 05/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5384 NW 4TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-4911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-953-4975
-----------------------------------------------------
Fax | 786-953-4975
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5384 NW 4TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-4911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-953-4975
-----------------------------------------------------
Fax | 786-953-6342
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NORMA VAZQUEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-281-2439
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 13115
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------