Provider Demographics
NPI:1730560434
Name:JESUS GROUP HOME LLC.
Entity type:Organization
Organization Name:JESUS GROUP HOME LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ZULY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:HHA
Authorized Official - Phone:786-266-6852
Mailing Address - Street 1:15504 SW 104TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-1458
Mailing Address - Country:US
Mailing Address - Phone:786-592-2281
Mailing Address - Fax:
Practice Address - Street 1:15504 SW 104TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-1458
Practice Address - Country:US
Practice Address - Phone:786-592-2281
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities