MEDICARE: 305 SWEET HOME ALF LLC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	3104A0625X	Assisted Living Facility (Mental Illness)
2	3104A0630X	Assisted Living Facility (Behavioral Disturbances)
3	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1770179582
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	305 SWEET HOME ALF LLC.

Provider Business Mailing Address
First Line	:	3910 NW 165TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33054-6223
Country	:	US
Telephone Number	:	786-567-1322
Fax Number	:

Provider Business Practice Location Address
First Line	:	3910 NW 165TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33054-6223
Country	:	US
Telephone Number	:	786-567-1322
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KARELYS HERNANDEZ
Credential	:
Telephone Number	:	786-567-1322

Provider Enumeration Date	:	12/15/2020
Last Update Date	:	12/15/2020

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