MEDICARE: MARINA ASSISTED LIVING FACILITY LLC

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	AL11199	FL

General Provider Information

NPI Number	:	1952725483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARINA ASSISTED LIVING FACILITY LLC

Provider Business Mailing Address
First Line	:	6702 W CLIFTON ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33634-5012
Country	:	US
Telephone Number	:	813-956-2663
Fax Number	:

Provider Business Practice Location Address
First Line	:	6702 W CLIFTON ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33634-5012
Country	:	US
Telephone Number	:	813-956-2663
Fax Number	:	813-882-0241

Authorized Official
Title or Position	:	OWNER
Name	:	RUBERT DOMINGUEZ
Credential	:
Telephone Number	:	813-956-2663

Provider Enumeration Date	:	02/04/2014
Last Update Date	:	02/05/2014

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