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General NPI Number Information
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NPI Number | 1417600313
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Entity Type | Organization
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Legal Business Name | STARLINE GROUP HOME
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Dates
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Enumeration Date | 01/31/2022
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Last Update Date | 01/31/2022
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Provider Practice Location Address
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Address Line | 820 SW DEL RIO BLVD FL 34953
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City | PORT ST LUCIE
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State | FL
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Zip | 34953-1979
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Country | US
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Telephone | 177-222-4974
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Fax |
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Provider Business Mailing Address
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Address Line | 820 SW DEL RIO BLVD FL 34953
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City | PORT ST LUCIE
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State | FL
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Zip | 34953-1979
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Country | US
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Telephone | 177-222-4974
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | AGNES JOAN LESLIE
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Credential |
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Telephone | 772-224-9746
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State |
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