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General NPI Number Information
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NPI Number | 1609322866
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Entity Type | Organization
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Legal Business Name | MIRA GROUP HOME
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Dates
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Enumeration Date | 08/28/2016
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Last Update Date | 08/28/2016
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Provider Practice Location Address
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Address Line | 1501 CREST CT
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City | VALRICO
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State | FL
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Zip | 33594-5107
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Country | US
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Telephone | 813-654-6579
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Fax |
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Provider Business Mailing Address
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Address Line | 1501 CREST CT
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City | VALRICO
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State | FL
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Zip | 33594-5107
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Country | US
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Telephone | 813-654-6579
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. PATRICIA LOUISE MIRA
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Credential |
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Telephone | 813-654-6579
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 595798
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License Number State | FL
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