Provider Demographics
NPI:1922305200
Name:MIAMI GARDENS MANOR, INC.
Entity Type:Organization
Organization Name:MIAMI GARDENS MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NOVELETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEHARIE- THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-815-8171
Mailing Address - Street 1:915 NW 175TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-4613
Mailing Address - Country:US
Mailing Address - Phone:954-815-8171
Mailing Address - Fax:
Practice Address - Street 1:915 NW 175TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33169-4613
Practice Address - Country:US
Practice Address - Phone:954-815-8171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11092310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility