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General NPI Number Information
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NPI Number | 1750728812
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Entity Type | Organization
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Legal Business Name | CRYSTAL GEM MANOR
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Dates
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Enumeration Date | 05/30/2013
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Last Update Date | 05/30/2013
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Provider Practice Location Address
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Address Line | 10845 W GEM ST
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City | CRYSTAL RIVER
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State | FL
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Zip | 34428-6682
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Country | US
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Telephone | 352-794-7601
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Fax |
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Provider Business Mailing Address
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Address Line | 300 71ST ST STE 410
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City | MIAMI BEACH
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State | FL
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Zip | 33141-3092
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Country | US
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Telephone | 305-868-1830
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JORGE A HERNANDO
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Credential |
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Telephone | 305-868-1830
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL10687
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License Number State | FL
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