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General NPI Number Information
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NPI Number | 1932609435
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Entity Type | Organization
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Legal Business Name | MARLEE'S GROUP HOME LLC
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Dates
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Enumeration Date | 02/20/2018
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Last Update Date | 02/20/2018
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Provider Practice Location Address
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Address Line | 3861 SW ROSSER BLVD
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34953-7084
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Country | US
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Telephone | 954-600-9295
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Fax |
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Provider Business Mailing Address
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Address Line | 3861 SW ROSSER BLVD
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34953-7084
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Country | US
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Telephone | 954-600-9295
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Fax |
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Authorized Official
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Title or Position | OWNER/ MANAGER
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Name | YVENA VIXAMAR
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Credential | RN
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Telephone | 954-600-9295
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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