Provider Demographics
NPI:1508149931
Name:FRIENDLY HEARTS GROUP HOME INC
Entity Type:Organization
Organization Name:FRIENDLY HEARTS GROUP HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALYSNE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-253-9646
Mailing Address - Street 1:10542 SW 161ST AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-4574
Mailing Address - Country:US
Mailing Address - Phone:305-382-9646
Mailing Address - Fax:305-382-9646
Practice Address - Street 1:10542 SW 161ST AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-4574
Practice Address - Country:US
Practice Address - Phone:305-382-9646
Practice Address - Fax:305-382-9646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11-988-GH320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003928100Medicaid