MEDICARE: MYRNA DORAME ALF OWNER

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	AL10039H	AZ

General Provider Information

NPI Number	:	1194337568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYRNA DORAME ALF OWNER

Provider Business Mailing Address
First Line	:	1532 S PERLMAN AVE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85710-8523
Country	:	US
Telephone Number	:	520-393-9389
Fax Number	:	520-741-1465

Provider Business Practice Location Address
First Line	:	1532 S PERLMAN AVE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85710-8523
Country	:	US
Telephone Number	:	520-393-9389
Fax Number	:	520-741-1465

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2020
Last Update Date	:	08/18/2020

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