Healthcare Provider Details

I. General information

NPI: 1003699380
Provider Name (Legal Business Name): PRIDE DETOX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2023
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 E 15TH ST
LONG BEACH CA
90804-2944
US

IV. Provider business mailing address

1414 N D ST
LAKE WORTH BEACH FL
33460-1761
US

V. Phone/Fax

Practice location:
  • Phone: 866-465-6889
  • Fax: 561-671-7512
Mailing address:
  • Phone: 866-465-6889
  • Fax: 561-671-7512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DONNA WEINBERGER
Title or Position: CEO
Credential:
Phone: 561-460-1318