Provider Demographics
NPI:1720256829
Name:ST. MARY ADULT CARE
Entity Type:Organization
Organization Name:ST. MARY ADULT CARE
Other - Org Name:ST. MARY ADULT CARE II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-393-8122
Mailing Address - Street 1:PO BOX 771120
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-0019
Mailing Address - Country:US
Mailing Address - Phone:786-393-8122
Mailing Address - Fax:305-408-1263
Practice Address - Street 1:11271 SW 229TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33170-7563
Practice Address - Country:US
Practice Address - Phone:786-504-2397
Practice Address - Fax:305-408-1263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL110693104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL142850100Medicaid
FL692848000Medicaid