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General NPI Number Information
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NPI Number | 1144759531
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Entity Type | Organization
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Legal Business Name | SPIRIT RESIDENTIAL GROUP HOME
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Dates
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Enumeration Date | 06/08/2017
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Last Update Date | 06/08/2017
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Provider Practice Location Address
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Address Line | 17311 N.W 33 CT
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City | MIAMI GARDENS
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State | FL
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Zip | 33056
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Country | US
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Telephone | 305-623-4618
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Fax |
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Provider Business Mailing Address
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Address Line | 17311 NW 33RD CT
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City | MIAMI GARDENS
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State | FL
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Zip | 33056-4218
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | LOLA BAIN
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Credential |
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Telephone | 305-623-4618
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD1600X
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Taxonomy Name | Developmental Disabilities Clinic/Center
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License Number |
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License Number State |
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