Provider Demographics
NPI:1447600663
Name:DIVINE GALLO HOUSE ALF, LLC
Entity Type:Organization
Organization Name:DIVINE GALLO HOUSE ALF, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ASHIT
Authorized Official - Middle Name:
Authorized Official - Last Name:VIJAPURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-966-5646
Mailing Address - Street 1:1911 W DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6509
Mailing Address - Country:US
Mailing Address - Phone:646-673-0044
Mailing Address - Fax:
Practice Address - Street 1:9110 STAR TRL
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34654-2542
Practice Address - Country:US
Practice Address - Phone:727-378-8065
Practice Address - Fax:727-378-8249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-19
Last Update Date:2016-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL119326393104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness