=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700295698
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ANGELS RETIREMENT HOME, CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2014
-----------------------------------------------------
Last Update Date | 08/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14714 S.W. 177 TERRACE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33187-7705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-378-4406
-----------------------------------------------------
Fax | 305-378-4406
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14714 S.W. 177 TERRACE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33187-7705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-815-2323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JENNY M. RODRIGUEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-815-2323
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 9523
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------