Provider Demographics
NPI:1659773257
Name:LUCILLES LOVING CARE
Entity Type:Organization
Organization Name:LUCILLES LOVING CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:DENBOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-623-0710
Mailing Address - Street 1:17820 NW 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-4736
Mailing Address - Country:US
Mailing Address - Phone:305-623-0710
Mailing Address - Fax:305-622-9629
Practice Address - Street 1:17820 NW 22ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-4736
Practice Address - Country:US
Practice Address - Phone:305-623-0710
Practice Address - Fax:305-622-9629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL3952320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL140490300Medicaid