Healthcare Provider Details

I. General information

NPI: 1629431879
Provider Name (Legal Business Name): FLORIDA YOUTH SERVICES SOUTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 N STATE ROAD 7
LAUDERDALE LAKES FL
33319-5883
US

IV. Provider business mailing address

4420 NW 15TH ST
LAUDERHILL FL
33313-5621
US

V. Phone/Fax

Practice location:
  • Phone: 954-822-4891
  • Fax:
Mailing address:
  • Phone: 954-822-4891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. STEPHAN BENSON
Title or Position: CEO
Credential:
Phone: 954-822-4891