Provider Demographics
NPI:1720437890
Name:MOSES GROUP HOME LLC
Entity Type:Organization
Organization Name:MOSES GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY-ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-214-8142
Mailing Address - Street 1:4273 SW DIDO DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6434
Mailing Address - Country:US
Mailing Address - Phone:201-214-8142
Mailing Address - Fax:
Practice Address - Street 1:4273 SW DIDO DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-6434
Practice Address - Country:US
Practice Address - Phone:201-214-8142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities