Provider Demographics
NPI:1629117163
Name:ST. AUGUSTINE GROUP HOMES, INC
Entity Type:Organization
Organization Name:ST. AUGUSTINE GROUP HOMES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-824-4391
Mailing Address - Street 1:1735 STATE ROAD 16
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-0807
Mailing Address - Country:US
Mailing Address - Phone:904-824-4391
Mailing Address - Fax:904-826-3835
Practice Address - Street 1:1735 STATE ROAD 16
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-0807
Practice Address - Country:US
Practice Address - Phone:904-824-4391
Practice Address - Fax:904-826-3835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL320600000X, 320600000X, 320600000X, 320600000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities