=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336540129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KRISTI HOUSE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2014
-----------------------------------------------------
Last Update Date | 09/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1265 NW 12TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33136-2140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-547-6800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1265 NW 12TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33136-2140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-547-6800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | GERTRUDE NOVICKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-547-6836
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------