Healthcare Provider Details

I. General information

NPI: 1932543634
Provider Name (Legal Business Name): FIRST IMPRESSIONS COMMUNITY DEVELOPEMENT CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13366 SW 288TH ST
HOMESTEAD FL
33033-1927
US

IV. Provider business mailing address

20101 NW 34TH CT
MIAMI GARDENS FL
33056-1768
US

V. Phone/Fax

Practice location:
  • Phone: 561-572-6250
  • Fax: 305-248-4284
Mailing address:
  • Phone: 561-572-6250
  • Fax: 305-248-4284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SHATARIA BRIDGES MOSS
Title or Position: PRESIDENT
Credential:
Phone: 561-572-6250