=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003172073
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ESTHER'S GROUP HOME CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2012
-----------------------------------------------------
Last Update Date | 04/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20115 HIGHLAND LAKES BLVD
-----------------------------------------------------
City | N MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33179-2813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-931-8023
-----------------------------------------------------
Fax | 305-792-7449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20115 HIGHLAND LAKES BLVD
-----------------------------------------------------
City | N MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33179-2813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-931-8023
-----------------------------------------------------
Fax | 305-792-7449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. ESTHER R DELVA
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 305-931-8023
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | 11255DH
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 11255DH
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------