Provider Demographics
NPI:1104267731
Name:SOUTH FLORIDA RECOVERY CENTER, LLC
Entity type:Organization
Organization Name:SOUTH FLORIDA RECOVERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:IACULLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-715-9288
Mailing Address - Street 1:4010 S 57TH AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-4301
Mailing Address - Country:US
Mailing Address - Phone:561-275-1001
Mailing Address - Fax:
Practice Address - Street 1:4010 S 57TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-4301
Practice Address - Country:US
Practice Address - Phone:561-275-1001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1550AD149401324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1550AD149401OtherDCF LICENSE