Provider Demographics
NPI:1659637262
Name:DIVINE LIVING IN HIALEAH, LLC
Entity Type:Organization
Organization Name:DIVINE LIVING IN HIALEAH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:YADELKIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-417-7246
Mailing Address - Street 1:70 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-2732
Mailing Address - Country:US
Mailing Address - Phone:305-888-0779
Mailing Address - Fax:305-888-8970
Practice Address - Street 1:70 E 21ST ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-2732
Practice Address - Country:US
Practice Address - Phone:305-888-0779
Practice Address - Fax:305-888-8970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL12000003110OtherFLORIDA DEPARTMENT OF STATE