Healthcare Provider Details

I. General information

NPI: 1689300568
Provider Name (Legal Business Name): MVP GROUP HOME I LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

266 N TWIN MAPLE RD
SAINT AUGUSTINE FL
32084-8398
US

IV. Provider business mailing address

701 SAN JOSE RD
ST AUGUSTINE FL
32086-6551
US

V. Phone/Fax

Practice location:
  • Phone: 904-669-8446
  • Fax:
Mailing address:
  • Phone: 904-669-8446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CATHERINE CASON
Title or Position: OWNER
Credential:
Phone: 904-669-8446