MEDICARE: ARK PROVISION ENTERPRISES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD1600X	Developmental Disabilities Clinic/Center

General Provider Information

NPI Number	:	1013683440
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARK PROVISION ENTERPRISES, INC.

Provider Business Mailing Address
First Line	:	17333 NW 62ND PL
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33015-4502
Country	:	US
Telephone Number	:	305-826-3256
Fax Number	:

Provider Business Practice Location Address
First Line	:	5911 NW 173RD DR UNIT 11
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33015-5122
Country	:	US
Telephone Number	:	786-655-9992
Fax Number	:	786-734-8142

Authorized Official
Title or Position	:	VP
Name	:	VICENTE CHANG
Credential	:
Telephone Number	:	786-655-9992

Provider Enumeration Date	:	08/17/2021
Last Update Date	:	08/17/2021

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