Provider Demographics
NPI:1144759531
Name:SPIRIT RESIDENTIAL GROUP HOME
Entity Type:Organization
Organization Name:SPIRIT RESIDENTIAL GROUP HOME
Other - Org Name:SPIRIT RESIDENTIAL GROUP HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-623-4618
Mailing Address - Street 1:17311 NW 33RD CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-4218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17311 N.W 33 CT
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056
Practice Address - Country:US
Practice Address - Phone:305-623-4618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities