Healthcare Provider Details

I. General information

NPI: 1659862258
Provider Name (Legal Business Name): AMAZING GRACE RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 05/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3678 W OAKLAND PARK BLVD
LAUDERDALE LAKES FL
33311-1148
US

IV. Provider business mailing address

2953 NW 192ND TER
MIAMI GARDENS FL
33056-2477
US

V. Phone/Fax

Practice location:
  • Phone: 954-709-1210
  • Fax:
Mailing address:
  • Phone: 954-709-1210
  • 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: ALEXIS CHANEL WALKER
Title or Position: OWNER/DIRECTER
Credential:
Phone: 954-709-1210