Provider Demographics
NPI:1144753641
Name:BAIN, LOLA
Entity Type:Individual
Prefix:
First Name:LOLA
Middle Name:
Last Name:BAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17311 N.W 3 CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33056
Mailing Address - Country:US
Mailing Address - Phone:305-623-4618
Mailing Address - Fax:305-623-4618
Practice Address - Street 1:17311 NW 33RD CT
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-4218
Practice Address - Country:US
Practice Address - Phone:305-623-4618
Practice Address - Fax:305-623-4618
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid