MEDICARE: ROSALIE GROUP HOME OF MIAMI 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility		FL

General Provider Information

NPI Number	:	1679918791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROSALIE GROUP HOME OF MIAMI INC.

Provider Business Mailing Address
First Line	:	1520 NW 84TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33147-4332
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1520 NW 84TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33147-4332
Country	:	US
Telephone Number	:	305-525-5958
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	GLORIA FORTUNE
Credential	:
Telephone Number	:	305-525-5958

Provider Enumeration Date	:	05/02/2013
Last Update Date	:	05/02/2013

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