MEDICARE: THE HAVEN DETOX FT. PIERCE, 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	324500000X	Substance Abuse Rehabilitation Facility		FL

General Provider Information

NPI Number	:	1205209004
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE HAVEN DETOX FT. PIERCE, LLC

Provider Business Mailing Address
First Line	:	3951 HAVERHILL RD N
Second Line	:	APT 120-121
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33417-8154
Country	:	US
Telephone Number	:	561-616-9000
Fax Number	:

Provider Business Practice Location Address
First Line	:	4707 OLEANDER AVE
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-4209
Country	:	US
Telephone Number	:	561-616-9000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KIRILL VESSELOV
Credential	:
Telephone Number	:	561-616-9000

Provider Enumeration Date	:	11/03/2015
Last Update Date	:	11/03/2015

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