Provider Demographics
NPI:1861236440
Name:INTEGRATION GROUP HOME LLC
Entity type:Organization
Organization Name:INTEGRATION GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:NDIFOR
Authorized Official - Last Name:FOMEKON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-227-5811
Mailing Address - Street 1:4800 SAN REMO DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8642
Mailing Address - Country:US
Mailing Address - Phone:612-227-5811
Mailing Address - Fax:
Practice Address - Street 1:4800 SAN REMO DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-8642
Practice Address - Country:US
Practice Address - Phone:612-227-5811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities