Basic Information
| Provider Information | |||||||||
| NPI: | 1144749771 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLAZA OF PEMBROKE ALF LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3535 SW 52ND AVE | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330235420 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3535 SW 52ND AVE | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330235420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549618111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2017 | ||||||||
| LastUpdateDate: | 09/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | KOHN | ||||||||
| AuthorizedOfficialFirstName: | ZEVI | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7183382999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 5120 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 5120 | 01 | FL | ALF | OTHER |