Provider Demographics
NPI:1194337568
Name:DORAME, MYRNA (ALF OWNER)
Entity type:Individual
Prefix:
First Name:MYRNA
Middle Name:
Last Name:DORAME
Suffix:
Gender:F
Credentials:ALF OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 S PERLMAN AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-8523
Mailing Address - Country:US
Mailing Address - Phone:520-393-9389
Mailing Address - Fax:520-741-1465
Practice Address - Street 1:1532 S PERLMAN AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-8523
Practice Address - Country:US
Practice Address - Phone:520-393-9389
Practice Address - Fax:520-741-1465
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10039H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility