Provider Demographics
NPI:1548979800
Name:PRESTIGE GROUP HOME INC
Entity type:Organization
Organization Name:PRESTIGE GROUP HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:772-349-8608
Mailing Address - Street 1:2278 SW PLYMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2379
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:772-777-2088
Practice Address - Street 1:2278 SW PLYMOUTH ST
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2379
Practice Address - Country:US
Practice Address - Phone:772-879-4575
Practice Address - Fax:772-777-2088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL685946196Medicaid