=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952846636
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVA CARES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2017
-----------------------------------------------------
Last Update Date | 01/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1108 BLACK KNIGHT DR
-----------------------------------------------------
City | VALRICO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33594-5800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-300-6177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10107 PADDOCK OAKS DR
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33569-8741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-300-6177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROGER THOMAS DEROSA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-300-6177
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL12747
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------