=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588921290
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAYMOND'S GROUP HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2012
-----------------------------------------------------
Last Update Date | 04/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8150 SW 6TH ST
-----------------------------------------------------
City | N LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33068-2014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-549-0948
-----------------------------------------------------
Fax | 786-362-6971
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8150 SW 6TH ST
-----------------------------------------------------
City | N LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33068-2014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-549-0948
-----------------------------------------------------
Fax | 786-362-6971
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DAISY GRACIANO
-----------------------------------------------------
Credential | HEALTH EDUCATER
-----------------------------------------------------
Telephone | 954-549-0948
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320700000X
-----------------------------------------------------
Taxonomy Name | Physical Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 1025746H
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------