Healthcare Provider Details

I. General information

NPI: 1356156186
Provider Name (Legal Business Name): SHAN GROUP 4 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 NW 53RD ST 125 OFFICE18
BOCA RATON FL
33487-8235
US

IV. Provider business mailing address

15251 NE 18TH AVE STE 9
NORTH MIAMI BEACH FL
33162-6039
US

V. Phone/Fax

Practice location:
  • Phone: 561-677-3133
  • Fax: 561-879-4025
Mailing address:
  • Phone: 305-627-3103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ALI MANDSOURWALA
Title or Position: CEO
Credential:
Phone: 561-677-3133