MEDICARE: MIRELLA'S ASSISTED LIVING 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	310400000X	Assisted Living Facility	11693	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144645854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRELLA'S ASSISTED LIVING LLC

Provider Business Mailing Address
First Line	:	3003 W BEACH ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-2928
Country	:	US
Telephone Number	:	813-500-3508
Fax Number	:

Provider Business Practice Location Address
First Line	:	3003 W BEACH ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-2928
Country	:	US
Telephone Number	:	813-500-3508
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MIRELLA R RUBIO
Credential	:
Telephone Number	:	813-500-3508

Provider Enumeration Date	:	03/04/2014
Last Update Date	:	03/04/2014

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