Provider Demographics
NPI:1639325459
Name:MIDWAY RETIREMENT RESIDENCE
Entity Type:Organization
Organization Name:MIDWAY RETIREMENT RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSITRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSANA
Authorized Official - Middle Name:G
Authorized Official - Last Name:GROISMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-266-1499
Mailing Address - Street 1:93 SW 79TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-2233
Mailing Address - Country:US
Mailing Address - Phone:305-266-1499
Mailing Address - Fax:
Practice Address - Street 1:93 SW 79TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2233
Practice Address - Country:US
Practice Address - Phone:305-266-1499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL6647310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility