=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770179582
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 305 SWEET HOME ALF LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2020
-----------------------------------------------------
Last Update Date | 12/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3910 NW 165TH ST
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33054-6223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-567-1322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3910 NW 165TH ST
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33054-6223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-567-1322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KARELYS HERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-567-1322
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3104A0630X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------