MEDICARE: CELEBRATE LIFE RECOVERY CENTER PHASE II, 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

General Provider Information

NPI Number	:	1417491820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CELEBRATE LIFE RECOVERY CENTER PHASE II, LLC

Provider Business Mailing Address
First Line	:	4955 NW 84TH RD
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33067-1973
Country	:	US
Telephone Number	:	954-951-6005
Fax Number	:	954-951-6006

Provider Business Practice Location Address
First Line	:	6043 KIMBERLY BLVD STE U
Second Line	:
City	:	NORTH LAUDERDALE
State	:	FL
Zip	:	33068-2826
Country	:	US
Telephone Number	:	954-951-6005
Fax Number	:	954-951-6006

Authorized Official
Title or Position	:	ONBOARDING SUPERVISOR
Name	:	KELI KORNMILLER
Credential	:
Telephone Number	:	561-672-8345

Provider Enumeration Date	:	12/05/2016
Last Update Date	:	12/05/2016

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