Provider Demographics
NPI:1972365799
Name:MAYBELLE GROUP HOME LLC
Entity type:Organization
Organization Name:MAYBELLE GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WAVENEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GITTENS-WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-966-7399
Mailing Address - Street 1:7202 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604
Mailing Address - Country:US
Mailing Address - Phone:813-966-7399
Mailing Address - Fax:813-212-6002
Practice Address - Street 1:7207 LAKESHORE DRIVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604
Practice Address - Country:US
Practice Address - Phone:813-966-7399
Practice Address - Fax:813-212-6002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term CareGroup - Single Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care