Healthcare Provider Details

I. General information

NPI: 1700125374
Provider Name (Legal Business Name): LILLITH MORRIS GROUP HOME INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2013
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 SAN AMBROSIO ST
PUNTA GORDA FL
33983-5767
US

IV. Provider business mailing address

364 SAN AMBROSIO ST
PUNTA GORDA FL
33983-5767
US

V. Phone/Fax

Practice location:
  • Phone: 941-623-0404
  • Fax: 941-623-0404
Mailing address:
  • Phone: 941-623-0404
  • Fax: 941-623-0404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number10001505
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number10001505
License Number StateFL

VIII. Authorized Official

Name: DEBORAH JOSHUA
Title or Position: DIRECTOR
Credential:
Phone: 941-623-0404