Provider Demographics
NPI:1215440227
Name:FLORIDA LIFE RECOVERY AND REHABILITATION LLC
Entity type:Organization
Organization Name:FLORIDA LIFE RECOVERY AND REHABILITATION LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PACHECO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-960-7104
Mailing Address - Street 1:590 E 49TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-1962
Mailing Address - Country:US
Mailing Address - Phone:305-960-7104
Mailing Address - Fax:305-907-5221
Practice Address - Street 1:590 E 49TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-1962
Practice Address - Country:US
Practice Address - Phone:305-960-7104
Practice Address - Fax:305-907-5221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-13
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105937600Medicaid