MEDICARE: MIS ABUELOS HOME CARE CORP.

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	AL11421	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11421	OTHER	FL	ASSISTED LIVING FACILITY AHCA LICENSE

General Provider Information

NPI Number	:	1326368960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIS ABUELOS HOME CARE CORP.

Provider Business Mailing Address
First Line	:	8422 WOODLAKE DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-1717
Country	:	US
Telephone Number	:	813-886-1380
Fax Number	:	813-886-1430

Provider Business Practice Location Address
First Line	:	8422 WOODLAKE DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-1717
Country	:	US
Telephone Number	:	813-886-1380
Fax Number	:	813-886-1430

Authorized Official
Title or Position	:	VICEPRESIDENT
Name	:	MR. DAGOBERTO MEDINA
Credential	:
Telephone Number	:	813-784-0328

Provider Enumeration Date	:	06/06/2010
Last Update Date	:	08/28/2013

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