Provider Demographics
NPI:1902635758
Name:DREAM GROUP HOME LLC
Entity type:Organization
Organization Name:DREAM GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORINE
Authorized Official - Middle Name:
Authorized Official - Last Name:NZOFANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-215-6186
Mailing Address - Street 1:5524 HAUN DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-3758
Mailing Address - Country:US
Mailing Address - Phone:508-215-6186
Mailing Address - Fax:
Practice Address - Street 1:5524 HAUN DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-3758
Practice Address - Country:US
Practice Address - Phone:508-215-6186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities