=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659766780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ESENCIA DE LA VIDA ADULT DAY CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2015
-----------------------------------------------------
Last Update Date | 06/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4750 W FLAGLER ST
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134-1452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-488-3503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4750 W FLAGLER ST
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134-1452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-488-3503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATOR
-----------------------------------------------------
Name | MRS. YAQUELYN GONZALEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-488-3503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | 9284
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------