Provider Demographics
NPI:1700208378
Name:BLUE LAGOON GROUP HOME INC
Entity Type:Organization
Organization Name:BLUE LAGOON GROUP HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EUGENIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-657-7205
Mailing Address - Street 1:21100 NW 28TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-1105
Mailing Address - Country:US
Mailing Address - Phone:786-657-7205
Mailing Address - Fax:
Practice Address - Street 1:21100 NW 28TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-1105
Practice Address - Country:US
Practice Address - Phone:786-657-7205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========Medicaid