MEDICARE: JERUSALEM GROUP HOME LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD1600X	Developmental Disabilities Clinic/Center

General Provider Information

NPI Number	:	1346866209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JERUSALEM GROUP HOME LLC

Provider Business Mailing Address
First Line	:	2440 SW 82ND TER
Second Line	:
City	:	MIRAMAR
State	:	FL
Zip	:	33025-2134
Country	:	US
Telephone Number	:	305-763-7043
Fax Number	:

Provider Business Practice Location Address
First Line	:	2440 SW 82ND TER
Second Line	:
City	:	MIRAMAR
State	:	FL
Zip	:	33025-2134
Country	:	US
Telephone Number	:	305-763-7043
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ROSE JEAN BAPTISTE
Credential	:
Telephone Number	:	305-763-7043

Provider Enumeration Date	:	06/17/2020
Last Update Date	:	06/17/2020

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