1356612774 NPI number — HELEN HOMES OF SOUTH DADE, LLC

Table of content: (NPI 1356612774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356612774 NPI number — HELEN HOMES OF SOUTH DADE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HELEN HOMES OF SOUTH DADE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HOMESTEAD MANOR, A PALACE COMMUNITY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356612774
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10850 SW 113TH PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33176-3227
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-270-7000
Provider Business Mailing Address Fax Number:
305-598-3847

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1330 NW 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMESTEAD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33030-4212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-248-0271
Provider Business Practice Location Address Fax Number:
305-248-7654
Provider Enumeration Date:
01/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SHAHAM
Authorized Official First Name:
JACOB
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
305-270-7030

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004601700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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