Healthcare Provider Details

I. General information

NPI: 1417203175
Provider Name (Legal Business Name): THE GRAPEVINE HOUSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

381 NE 5TH AVE
DELRAY BEACH FL
33483-5532
US

IV. Provider business mailing address

381 NE 5TH AVE
DELRAY BEACH FL
33483-5532
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1550AD290601
License Number StateFL

VIII. Authorized Official

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