Provider Demographics
NPI:1043410103
Name:MARY'S HOME, INC.
Entity type:Organization
Organization Name:MARY'S HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEDEIDY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-715-1896
Mailing Address - Street 1:14158 NW 88 PLACE
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33018
Mailing Address - Country:US
Mailing Address - Phone:786-401-6639
Mailing Address - Fax:786-400-8606
Practice Address - Street 1:14158 NW 88 PLACE
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33018
Practice Address - Country:US
Practice Address - Phone:786-401-6639
Practice Address - Fax:786-400-8606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10073310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL141203500Medicaid