MEDICARE: HOGAR LA 3RD EDAD

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	AL10418	FL

General Provider Information

NPI Number	:	1679784326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOGAR LA 3RD EDAD

Provider Business Mailing Address
First Line	:	2940 SW 114TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33165-2112
Country	:	US
Telephone Number	:	305-226-0683
Fax Number	:	305-225-1289

Provider Business Practice Location Address
First Line	:	2940 SW 114TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33165-2112
Country	:	US
Telephone Number	:	305-226-0683
Fax Number	:	305-225-1289

Authorized Official
Title or Position	:	OWNER
Name	:	NANCY GONZALEZ
Credential	:
Telephone Number	:	305-226-0683

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	08/22/2020

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