Provider Demographics
NPI:1083859128
Name:PALMETTO SENIOR CARE INC.
Entity Type:Organization
Organization Name:PALMETTO SENIOR CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA MATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-934-8770
Mailing Address - Street 1:6791 ROYAL MELBOURNE DR.
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015
Mailing Address - Country:US
Mailing Address - Phone:305-934-8770
Mailing Address - Fax:305-816-9996
Practice Address - Street 1:3157 W. 78TH PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016
Practice Address - Country:US
Practice Address - Phone:305-934-8770
Practice Address - Fax:305-816-9996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9143310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========Medicaid