Provider Demographics
NPI:1528381100
Name:CORDERO RESIDENCE
Entity Type:Organization
Organization Name:CORDERO RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANAIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLATE-MENESES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-344-6275
Mailing Address - Street 1:4111 SW 135TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3211
Mailing Address - Country:US
Mailing Address - Phone:786-344-6275
Mailing Address - Fax:
Practice Address - Street 1:4510 SW 106TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-5637
Practice Address - Country:US
Practice Address - Phone:305-559-2530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10430310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility