=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316341423
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEAN MCCURDIE ADULT FAMILY HOME CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2014
-----------------------------------------------------
Last Update Date | 10/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 390 NW 125TH ST
-----------------------------------------------------
City | NORTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33168-3650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-681-9763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 390 NW 125TH ST
-----------------------------------------------------
City | NORTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33168-3650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-681-9763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | JEAN MCCURDIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-356-3659
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 6906438
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------