Provider Demographics
NPI:1023772738
Name:FAITH GROUP HOME INC.
Entity type:Organization
Organization Name:FAITH GROUP HOME INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:LAROW
Authorized Official - Last Name:ROBERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-396-1247
Mailing Address - Street 1:836 W DESOTO ST STE 5E
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-2110
Mailing Address - Country:US
Mailing Address - Phone:352-396-1247
Mailing Address - Fax:352-394-2353
Practice Address - Street 1:836 W DESOTO ST STE 5E
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2110
Practice Address - Country:US
Practice Address - Phone:352-396-1247
Practice Address - Fax:352-394-2353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103245100Medicaid