MEDICARE: CASA EDAD DORADA ALF, 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	310400000X	Assisted Living Facility	AL12755	FL

General Provider Information

NPI Number	:	1114382413
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CASA EDAD DORADA ALF, INC.

Provider Business Mailing Address
First Line	:	11263 SW 35TH TER
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33165-3409
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11263 SW 35TH TER
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33165-3409
Country	:	US
Telephone Number	:	786-554-4313
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LISBET VARGAS
Credential	:
Telephone Number	:	786-554-4313

Provider Enumeration Date	:	12/31/2015
Last Update Date	:	12/31/2015

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