Healthcare Provider Details

I. General information

NPI: 1508415332
Provider Name (Legal Business Name): EXULTATION COMMUNITY RESOURCE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2019
Last Update Date: 09/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 N STATE ROAD 7 STE 401-2
LAUDERDALE LAKES FL
33319-4804
US

IV. Provider business mailing address

517 NW 16TH AVE
FORT LAUDERDALE FL
33311-8851
US

V. Phone/Fax

Practice location:
  • Phone: 954-478-5835
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: PHYLLIS MATHIS
Title or Position: CEO
Credential:
Phone: 954-478-5835