MEDICARE: MOSES GROUP HOME LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility
2	261QD1600X	Developmental Disabilities Clinic/Center
3	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1720437890
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOSES GROUP HOME LLC

Provider Business Mailing Address
First Line	:	4273 SW DIDO DR
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-6434
Country	:	US
Telephone Number	:	201-214-8142
Fax Number	:

Provider Business Practice Location Address
First Line	:	4273 SW DIDO DR
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-6434
Country	:	US
Telephone Number	:	201-214-8142
Fax Number	:

Authorized Official
Title or Position	:	MGR
Name	:	SHIRLEY-ANN MOSES
Credential	:
Telephone Number	:	201-214-8142

Provider Enumeration Date	:	06/08/2016
Last Update Date	:	06/08/2016

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