Provider Demographics
NPI:1346681129
Name:BLAIR GROUP HOME
Entity Type:Organization
Organization Name:BLAIR GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-837-3125
Mailing Address - Street 1:211 N SPARKMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-5011
Mailing Address - Country:US
Mailing Address - Phone:386-775-2165
Mailing Address - Fax:386-775-3165
Practice Address - Street 1:211 N SPARKMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-5011
Practice Address - Country:US
Practice Address - Phone:386-775-2165
Practice Address - Fax:386-775-3165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL678316396320900000X, 385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child