Healthcare Provider Details

I. General information

NPI: 1346681129
Provider Name (Legal Business Name): BLAIR GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2013
Last Update Date: 07/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N SPARKMAN AVE
ORANGE CITY FL
32763-5011
US

IV. Provider business mailing address

211 N SPARKMAN AVE
ORANGE CITY FL
32763-5011
US

V. Phone/Fax

Practice location:
  • Phone: 386-775-2165
  • Fax: 386-775-3165
Mailing address:
  • Phone: 386-775-2165
  • Fax: 386-775-3165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number678316396
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number678316396
License Number StateFL

VIII. Authorized Official

Name: MR. CRAIG ALAN BLAIR
Title or Position: MANAGER
Credential:
Phone: 386-837-3125