=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760693816
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ANGELS AGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13320 SW 71ST ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33183-2310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-408-7287
-----------------------------------------------------
Fax | 305-225-1289
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13320 SW 71ST ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33183-2310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-408-7287
-----------------------------------------------------
Fax | 305-225-1289
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | TANIA CORREA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-408-7287
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL 10053
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------