Provider Demographics
NPI:1104121466
Name:INTRAQUAL PREMIER INC
Entity type:Organization
Organization Name:INTRAQUAL PREMIER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-724-1974
Mailing Address - Street 1:19117 NW 33RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-7406
Mailing Address - Country:US
Mailing Address - Phone:305-621-1051
Mailing Address - Fax:305-628-4855
Practice Address - Street 1:19117 NW 33RD AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-7406
Practice Address - Country:US
Practice Address - Phone:305-621-1051
Practice Address - Fax:305-628-4855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11941310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility