Provider Demographics
NPI:1790979581
Name:SUN COAST VILLAGE I
Entity Type:Organization
Organization Name:SUN COAST VILLAGE I
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BANEGAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-228-6517
Mailing Address - Street 1:12785 SW 49TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-5401
Mailing Address - Country:US
Mailing Address - Phone:305-228-6517
Mailing Address - Fax:305-225-1289
Practice Address - Street 1:12785 SW 49TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-5401
Practice Address - Country:US
Practice Address - Phone:305-228-6517
Practice Address - Fax:305-225-1289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL7920310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL141274400Medicaid