Provider Demographics
NPI:1689885725
Name:TGL RESIDENCE
Entity Type:Organization
Organization Name:TGL RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-559-5917
Mailing Address - Street 1:3210 SW 104TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-3712
Mailing Address - Country:US
Mailing Address - Phone:305-559-5917
Mailing Address - Fax:305-225-1289
Practice Address - Street 1:3210 SW 104TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3712
Practice Address - Country:US
Practice Address - Phone:305-559-5917
Practice Address - Fax:305-225-1289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 5959310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL684140600Medicaid
FL141078400Medicaid