Provider Demographics
NPI:1689097982
Name:MIS ABUELOS HOME CARE CORP.
Entity Type:Organization
Organization Name:MIS ABUELOS HOME CARE CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAGOBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-784-0328
Mailing Address - Street 1:8422 WOODLAKE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-1717
Mailing Address - Country:US
Mailing Address - Phone:813-784-0328
Mailing Address - Fax:813-886-1430
Practice Address - Street 1:8422 WOODLAKE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-1717
Practice Address - Country:US
Practice Address - Phone:813-784-0328
Practice Address - Fax:813-886-1430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11421261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL11421OtherAHCA LICENSE