Provider Demographics
NPI:1760052955
Name:BELLAGIO PALMS ALF II INC
Entity Type:Organization
Organization Name:BELLAGIO PALMS ALF II INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRETTELL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-988-0659
Mailing Address - Street 1:21 NW 133RD PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33182-1642
Mailing Address - Country:US
Mailing Address - Phone:305-988-0659
Mailing Address - Fax:
Practice Address - Street 1:21 NW 133RD PL
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33182-1642
Practice Address - Country:US
Practice Address - Phone:305-988-0659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110775300Medicaid