Healthcare Provider Details

I. General information

NPI: 1902158025
Provider Name (Legal Business Name): GRACIOUS CARE RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2012
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 SE 10TH ST STE B
DEERFIELD BEACH FL
33441-5607
US

IV. Provider business mailing address

635 SE 10TH ST STE B
DEERFIELD BEACH FL
33441-5607
US

V. Phone/Fax

Practice location:
  • Phone: 754-201-2265
  • Fax:
Mailing address:
  • Phone: 754-201-2265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOSE FLORES
Title or Position: ACCOUNT SPECIALIST
Credential:
Phone: 754-201-2265