Healthcare Provider Details

I. General information

NPI: 1679910715
Provider Name (Legal Business Name): SOVEREIGN HEALTH OF FLORIDA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2013
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3331 E RIVERSIDE DR
FORT MYERS FL
33916-1457
US

IV. Provider business mailing address

PO BOX 5705
SAN CLEMENTE CA
92674-5705
US

V. Phone/Fax

Practice location:
  • Phone: 949-522-9553
  • Fax: 949-390-9899
Mailing address:
  • Phone: 949-625-0376
  • Fax: 949-390-9899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. RON GIRSKIS
Title or Position: BUSINESS OPERATIONS SPECIALIST
Credential:
Phone: 949-359-8273