Healthcare Provider Details

I. General information

NPI: 1386321180
Provider Name (Legal Business Name): BANYAN GULF BREEZE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 HICKORY SHORES RD
GULF BREEZE FL
32563-9143
US

IV. Provider business mailing address

225 N FEDERAL HWY
POMPANO BEACH FL
33062-4319
US

V. Phone/Fax

Practice location:
  • Phone: 754-206-8522
  • Fax: 850-677-0312
Mailing address:
  • Phone: 954-533-7705
  • Fax: 954-781-7173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: JOHN SORY
Title or Position: CEO
Credential:
Phone: 954-533-7705