Provider Demographics
NPI:1962117101
Name:AUTHENTIC LIVING CENTER, LLC
Entity type:Organization
Organization Name:AUTHENTIC LIVING CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KARMIVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:727-480-0107
Mailing Address - Street 1:25400 US HIGHWAY 19 N STE 156
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33763-2150
Mailing Address - Country:US
Mailing Address - Phone:727-480-0107
Mailing Address - Fax:727-499-7555
Practice Address - Street 1:25400 US HIGHWAY 19 N STE 156
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33763-2150
Practice Address - Country:US
Practice Address - Phone:727-480-0107
Practice Address - Fax:727-499-7555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-23
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100582700Medicaid