=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538468566
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BELLAGIO PALMS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2011
-----------------------------------------------------
Last Update Date | 03/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 NW 133RD PL
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33182-1642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-225-7119
-----------------------------------------------------
Fax | 305-225-1289
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 NW 133RD PL
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33182-1642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-225-7119
-----------------------------------------------------
Fax | 305-225-1289
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | TAHAMARA CHINEA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-225-7119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL11957
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------