Provider Demographics
NPI:1114313392
Name:AMBROSIA WELLNESS PROGRAM LLC
Entity type:Organization
Organization Name:AMBROSIA WELLNESS PROGRAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCEFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-578-8600
Mailing Address - Street 1:5220 HOOD RD
Mailing Address - Street 2:#101
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-8910
Mailing Address - Country:US
Mailing Address - Phone:561-721-8800
Mailing Address - Fax:
Practice Address - Street 1:5220 HOOD RD
Practice Address - Street 2:#101
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-8910
Practice Address - Country:US
Practice Address - Phone:561-721-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty