Provider Demographics
NPI:1134563562
Name:NELISHA FAMILY HOME LLC
Entity type:Organization
Organization Name:NELISHA FAMILY HOME LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:W
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:772-340-4671
Mailing Address - Street 1:3871 SW RAMSPECK ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953
Mailing Address - Country:US
Mailing Address - Phone:772-340-4671
Mailing Address - Fax:772-264-0592
Practice Address - Street 1:3871 SW RAMSPECK ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953
Practice Address - Country:US
Practice Address - Phone:772-340-4671
Practice Address - Fax:772-264-0592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12437310400000X
FL12692310400000X
310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFL024319000Medicaid