MEDICARE: BELLA ROSE ALF 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	310400000X	Assisted Living Facility	AL12409	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922434802
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BELLA ROSE ALF INC.

Provider Business Mailing Address
First Line	:	804 W YUKON ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33604-1236
Country	:	US
Telephone Number	:	813-410-0828
Fax Number	:	813-644-4833

Provider Business Practice Location Address
First Line	:	804 W YUKON ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33604-1236
Country	:	US
Telephone Number	:	813-410-0828
Fax Number	:	813-644-4833

Authorized Official
Title or Position	:	ADMINISTRATOR/ OWNER
Name	:	MR. ASRIEL LOPEZ
Credential	:
Telephone Number	:	813-410-0828

Provider Enumeration Date	:	09/23/2013
Last Update Date	:	09/23/2013

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