Healthcare Provider Details

I. General information

NPI: 1003172073
Provider Name (Legal Business Name): ESTHER'S GROUP HOME CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 04/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20115 HIGHLAND LAKES BLVD
N MIAMI BEACH FL
33179-2813
US

IV. Provider business mailing address

20115 HIGHLAND LAKES BLVD
N MIAMI BEACH FL
33179-2813
US

V. Phone/Fax

Practice location:
  • Phone: 305-931-8023
  • Fax: 305-792-7449
Mailing address:
  • Phone: 305-931-8023
  • Fax: 305-792-7449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number11255DH
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number11255DH
License Number StateFL

VIII. Authorized Official

Name: MS. ESTHER R DELVA
Title or Position: OWNER
Credential: RN
Phone: 305-931-8023