Provider Demographics
NPI:1215194451
Name:GOOD SUPPORT AGENCY
Entity Type:Organization
Organization Name:GOOD SUPPORT AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIRNA
Authorized Official - Middle Name:ESTEBANA
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-235-2684
Mailing Address - Street 1:14284 SW 176TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177
Mailing Address - Country:US
Mailing Address - Phone:395-235-2684
Mailing Address - Fax:305-235-6912
Practice Address - Street 1:14284 SW 176TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177
Practice Address - Country:US
Practice Address - Phone:305-235-2684
Practice Address - Fax:305-235-6912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL229223251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL682011596Medicaid
FL682011598Medicaid