Provider Demographics
NPI:1285159855
Name:PALM GARDENS RESIDENTIAL ADULT HOME, LLC.
Entity type:Organization
Organization Name:PALM GARDENS RESIDENTIAL ADULT HOME, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WIATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-755-2579
Mailing Address - Street 1:6620 SW 46TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-5904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6620 SW 46TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-5904
Practice Address - Country:US
Practice Address - Phone:305-755-2579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-04
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13035310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility