Provider Demographics
NPI:1063921401
Name:NEW LIFE MENTAL MANAGEMENT CORP
Entity type:Organization
Organization Name:NEW LIFE MENTAL MANAGEMENT CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:IHOSVANY
Authorized Official - Middle Name:
Authorized Official - Last Name:ESCOBAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-457-1263
Mailing Address - Street 1:3904 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-6233
Mailing Address - Country:US
Mailing Address - Phone:305-393-5303
Mailing Address - Fax:305-513-9338
Practice Address - Street 1:3904 NW 167TH ST
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-6233
Practice Address - Country:US
Practice Address - Phone:305-393-5303
Practice Address - Fax:305-513-9338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL685797Medicaid