Provider Demographics
NPI:1538333778
Name:COVENANT HOUSE FLORIDA, INC.
Entity type:Organization
Organization Name:COVENANT HOUSE FLORIDA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GRESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-568-7925
Mailing Address - Street 1:733 BREAKERS AVENUE
Mailing Address - Street 2:
Mailing Address - City:FT. LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-4100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:954-565-6551
Practice Address - Street 1:733 BREAKERS AVENUE
Practice Address - Street 2:
Practice Address - City:FT. LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-4100
Practice Address - Country:US
Practice Address - Phone:954-568-7939
Practice Address - Fax:954-565-6551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1006AD360701324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility