=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518120153
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CASA BELLA ALF
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2008
-----------------------------------------------------
Last Update Date | 07/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 670 W 72ND PL
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-4861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-556-7502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 670 W 72ND PL
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-4861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-556-7502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. JOSE MIGUEL ORTIZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-426-1493
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | AL10739
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------