MEDICARE: MIGDALIA'S ACLF

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	006683	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942613351
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIGDALIA'S ACLF

Provider Business Mailing Address
First Line	:	2302 N LINCOLN AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-3135
Country	:	US
Telephone Number	:	813-879-6980
Fax Number	:	813-879-8518

Provider Business Practice Location Address
First Line	:	2302 N LINCOLN AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-3135
Country	:	US
Telephone Number	:	813-879-6980
Fax Number	:	813-879-8518

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. TAILEEN GONZALES
Credential	:
Telephone Number	:	813-325-6906

Provider Enumeration Date	:	06/04/2014
Last Update Date	:	06/04/2014

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