Provider Demographics
NPI:1811392400
Name:GARDENIA HOME ALF,LLC
Entity Type:Organization
Organization Name:GARDENIA HOME ALF,LLC
Other - Org Name:GRANNY'S GARDEN HOME ALF, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:E
Authorized Official - Last Name:RE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-250-3345
Mailing Address - Street 1:12816 SW 67TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-1336
Mailing Address - Country:US
Mailing Address - Phone:786-499-0265
Mailing Address - Fax:786-250-3345
Practice Address - Street 1:12816 SW 67TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-1336
Practice Address - Country:US
Practice Address - Phone:786-499-0265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-26
Last Update Date:2014-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12558310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility