=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518413921
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAS DELICIAS ALF #2
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2016
-----------------------------------------------------
Last Update Date | 08/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3840 NW 184TH ST
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33055-2835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-623-7884
-----------------------------------------------------
Fax | 305-623-7884
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3840 NW 184TH ST
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33055-2835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-623-7884
-----------------------------------------------------
Fax | 305-623-7884
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | AMARILYS MARQUEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-253-4818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320700000X
-----------------------------------------------------
Taxonomy Name | Physical Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 12882
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------