MEDICARE: MISLYN PLACE OF HOPE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1467872382
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISLYN PLACE OF HOPE INC

Provider Business Mailing Address
First Line	:	410 NW 29TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33311-8548
Country	:	US
Telephone Number	:	212-470-7480
Fax Number	:

Provider Business Practice Location Address
First Line	:	410 NW 29TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33311-8548
Country	:	US
Telephone Number	:	212-470-7480
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	FIONA WHITE
Credential	:
Telephone Number	:	212-470-7480

Provider Enumeration Date	:	04/17/2014
Last Update Date	:	04/17/2014

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