=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548922958
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2021
-----------------------------------------------------
Last Update Date | 10/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 530 N PALMETTO AVE
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32771-1354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-499-7300
-----------------------------------------------------
Fax | 407-732-4665
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 115 TIMBERLACHEN CIR
-----------------------------------------------------
City | LAKE MARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32746-3336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-222-3700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | TOM J CAMPBELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-619-0678
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------