=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891172979
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANTAGE SENIOR LIVING FACILITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2015
-----------------------------------------------------
Last Update Date | 04/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 SW 47TH AVE
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33317-5618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-581-1084
-----------------------------------------------------
Fax | 954-734-8593
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1701 SW 47TH AVE
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33317-5618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-581-1084
-----------------------------------------------------
Fax | 954-734-8593
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | YONAYVIS RAMOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 754-368-1582
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL10472
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------