Healthcare Provider Details

I. General information

NPI: 1801628086
Provider Name (Legal Business Name): YAYA'S CASITA RESIDENTIAL GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2024
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 NW BURK AVE
LAKE CITY FL
32055-3730
US

IV. Provider business mailing address

17368 NW 173RD RD
ALACHUA FL
32615-0069
US

V. Phone/Fax

Practice location:
  • Phone: 251-458-3904
  • Fax:
Mailing address:
  • Phone: 251-458-3904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: YASHIRA MARIE MARRERO-SMITH
Title or Position: OWNER
Credential: RN
Phone: 251-458-3904