MEDICARE: DIVINE GALLO HOUSE ALF, 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)	11932639	FL

General Provider Information

NPI Number	:	1447600663
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE GALLO HOUSE ALF, LLC

Provider Business Mailing Address
First Line	:	1911 W DR MARTIN LUTHER KING JR BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-6509
Country	:	US
Telephone Number	:	646-673-0044
Fax Number	:

Provider Business Practice Location Address
First Line	:	9110 STAR TRL
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34654-2542
Country	:	US
Telephone Number	:	727-378-8065
Fax Number	:	727-378-8249

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ASHIT VIJAPURA
Credential	:	M.D.
Telephone Number	:	813-966-5646

Provider Enumeration Date	:	06/19/2016
Last Update Date	:	06/19/2016

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