1700208378 NPI number — BLUE LAGOON GROUP HOME INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700208378 NPI number — BLUE LAGOON GROUP HOME INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE LAGOON GROUP HOME INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700208378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21100 NW 28TH CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33056-1105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-657-7205
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21100 NW 28TH CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI GARDENS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33056-1105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-657-7205
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/15/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SANTANA
Authorized Official First Name:
EUGENIA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
786-657-7205

Provider Taxonomy Codes

  • Taxonomy code: 320900000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)