Provider Demographics
NPI:1417600313
Name:STARLINE GROUP HOME
Entity Type:Organization
Organization Name:STARLINE GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:LESLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-224-9746
Mailing Address - Street 1:820 SW DEL RIO BLVD FL 34953
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1979
Mailing Address - Country:US
Mailing Address - Phone:177-222-4974
Mailing Address - Fax:
Practice Address - Street 1:820 SW DEL RIO BLVD FL 34953
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-1979
Practice Address - Country:US
Practice Address - Phone:177-222-4974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services