Provider Demographics
NPI:1114550407
Name:LUCKY SOULS COMMUNITY MENTAL HEALTH LLC
Entity type:Organization
Organization Name:LUCKY SOULS COMMUNITY MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMBR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:BASTARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-965-4404
Mailing Address - Street 1:7811 CORAL WAY STE 137
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-6540
Mailing Address - Country:US
Mailing Address - Phone:305-965-4404
Mailing Address - Fax:
Practice Address - Street 1:7811 CORAL WAY STE 137
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-6540
Practice Address - Country:US
Practice Address - Phone:305-965-4404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-15
Last Update Date:2020-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health