Provider Demographics
NPI:1831357391
Name:HOME SWEET HOME
Entity type:Organization
Organization Name:HOME SWEET HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-987-2293
Mailing Address - Street 1:5120 SW 22ND ST
Mailing Address - Street 2:
Mailing Address - City:WEST PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33023-3224
Mailing Address - Country:US
Mailing Address - Phone:954-987-2293
Mailing Address - Fax:954-964-5274
Practice Address - Street 1:5120 SW 22ND ST
Practice Address - Street 2:
Practice Address - City:WEST PARK
Practice Address - State:FL
Practice Address - Zip Code:33023-3224
Practice Address - Country:US
Practice Address - Phone:954-987-2293
Practice Address - Fax:954-964-5274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL671558396Medicaid
FL671558398Medicaid