Provider Demographics
NPI:1114132305
Name:OUR LADY OF CHARITY ACLF, INC.
Entity Type:Organization
Organization Name:OUR LADY OF CHARITY ACLF, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CANDIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-586-6087
Mailing Address - Street 1:2927 SW 21ST TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-2319
Mailing Address - Country:US
Mailing Address - Phone:305-567-9321
Mailing Address - Fax:305-634-2076
Practice Address - Street 1:2927 SW 21ST TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-2319
Practice Address - Country:US
Practice Address - Phone:305-567-9321
Practice Address - Fax:305-634-2076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL8352310400000X
FL8352310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL140654000Medicaid