Provider Demographics
NPI:1881026136
Name:SAN JUDAS HOME CARE III
Entity Type:Organization
Organization Name:SAN JUDAS HOME CARE III
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:GRECIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-222-5456
Mailing Address - Street 1:251 NW 108TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33168-3222
Mailing Address - Country:US
Mailing Address - Phone:786-222-5469
Mailing Address - Fax:
Practice Address - Street 1:251 NW 108TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33168-3222
Practice Address - Country:US
Practice Address - Phone:786-222-5469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12298310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007396600Medicaid