Healthcare Provider Details

I. General information

NPI: 1053773168
Provider Name (Legal Business Name): HOUSE OF ESTHER GROUP HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 03/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9703 BAY COLONY DR
RIVERVIEW FL
33578-8374
US

IV. Provider business mailing address

9703 BAY COLONY DR
RIVERVIEW FL
33578-8374
US

V. Phone/Fax

Practice location:
  • Phone: 718-413-3982
  • Fax:
Mailing address:
  • Phone: 718-413-3982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. MERLINE CLARKE
Title or Position: OWNER/ADMINISTRATOR
Credential: LPN
Phone: 718-413-3982