MEDICARE: MI CASA ADULT LIVING FACILITY HOME, 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	11548	FL

General Provider Information

NPI Number	:	1205070539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MI CASA ADULT LIVING FACILITY HOME, INC

Provider Business Mailing Address
First Line	:	6856 SAINT AUGUSTINE RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-2818
Country	:	US
Telephone Number	:	904-739-3927
Fax Number	:	904-448-0130

Provider Business Practice Location Address
First Line	:	6856 SAINT AUGUSTINE RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-2818
Country	:	US
Telephone Number	:	904-739-3927
Fax Number	:	904-448-0130

Authorized Official
Title or Position	:	OWNER
Name	:	JESUS R CASTILLO
Credential	:
Telephone Number	:	904-739-3927

Provider Enumeration Date	:	04/30/2009
Last Update Date	:	07/20/2023

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