MEDICARE: LA HACIENDA GARDENS, LLC

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	3104A0625X	Assisted Living Facility (Mental Illness)	AL7680	FL
2	310400000X	Assisted Living Facility	AL7680	FL

General Provider Information

NPI Number	:	1144458738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA HACIENDA GARDENS, LLC

Provider Business Mailing Address
First Line	:	140 W 28TH ST
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33010-1606
Country	:	US
Telephone Number	:	786-419-6949
Fax Number	:

Provider Business Practice Location Address
First Line	:	75 E 7TH ST
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33010-4409
Country	:	US
Telephone Number	:	786-419-6949
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	CLAUDIA PACE
Credential	:
Telephone Number	:	786-419-6949

Provider Enumeration Date	:	06/23/2009
Last Update Date	:	06/23/2009

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