MEDICARE: AMBROSIA WELLNESS PROGRAM LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1114313392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMBROSIA WELLNESS PROGRAM LLC

Provider Business Mailing Address
First Line	:	5220 HOOD RD
Second Line	:	#101
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33418-8910
Country	:	US
Telephone Number	:	561-721-8800
Fax Number	:

Provider Business Practice Location Address
First Line	:	5220 HOOD RD
Second Line	:	#101
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33418-8910
Country	:	US
Telephone Number	:	561-721-8800
Fax Number	:

Authorized Official
Title or Position	:	CHIEF ADMINISTRATIVE OFFICER
Name	:	MR. TIMOTHY LOCEFF
Credential	:
Telephone Number	:	561-578-8600

Provider Enumeration Date	:	04/14/2015
Last Update Date	:	04/14/2015

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