=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629227111
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IBIS HOME CARE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2008
-----------------------------------------------------
Last Update Date | 09/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15088 SW 71ST LN
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33193-1911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-557-0260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15088 SW 71ST LN
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33193-1911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-557-0260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LAZARO PEREZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-557-0260
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 10579
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------