Provider Demographics
NPI: | 1780199018 |
---|---|
Name: | MARVELOUS BEHAVIORAL CARE CENTER CORP |
Entity Type: | Organization |
Organization Name: | MARVELOUS BEHAVIORAL CARE CENTER CORP |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MARLEN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GONZALEZ |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 305-812-9123 |
Mailing Address - Street 1: | 1125 NE 125TH ST STE 231 |
Mailing Address - Street 2: | |
Mailing Address - City: | NORTH MIAMI |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33161-5034 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 305-989-9307 |
Mailing Address - Fax: | 305-221-8415 |
Practice Address - Street 1: | 1125 NE 125TH ST STE 231 |
Practice Address - Street 2: | |
Practice Address - City: | NORTH MIAMI |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33161-5034 |
Practice Address - Country: | US |
Practice Address - Phone: | 305-989-9307 |
Practice Address - Fax: | 305-221-8415 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-12-08 |
Last Update Date: | 2018-06-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251B00000X | Agencies | Case Management |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | ========= | Other | IRS |