MEDICARE: ELENA PALACE

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		FL

General Provider Information

NPI Number	:	1750700571
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELENA PALACE

Provider Business Mailing Address
First Line	:	4012 SW 154TH CT
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33185-5442
Country	:	US
Telephone Number	:	786-615-4139
Fax Number	:

Provider Business Practice Location Address
First Line	:	4012 SW 154TH CT
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33185-5442
Country	:	US
Telephone Number	:	786-615-4139
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JUSTO LUIS DOMINGUEZ
Credential	:
Telephone Number	:	786-615-4139

Provider Enumeration Date	:	04/09/2014
Last Update Date	:	04/09/2014

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Directions to “ELENA PALACE ” Practice Location

Language	Start Address	Practice Location

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