Healthcare Provider Details

I. General information

NPI: 1598272098
Provider Name (Legal Business Name): BEACHSIDE DETOX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2018
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 54TH ST
WEST PALM BEACH FL
33407-2419
US

IV. Provider business mailing address

1101 54TH ST
WEST PALM BEACH FL
33407-2419
US

V. Phone/Fax

Practice location:
  • Phone: 561-365-3758
  • Fax: 772-448-4029
Mailing address:
  • Phone: 561-365-3758
  • Fax: 772-448-4029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberCERT-COMP-1001474
License Number StateFL

VIII. Authorized Official

Name: ANNEMARIE SINCAVAGE
Title or Position: CFO
Credential:
Phone: 561-901-4923