=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104173350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR INDEPENDENT LIVING OF BROWARD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2012
-----------------------------------------------------
Last Update Date | 08/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4800 N STATE ROAD 7 SUITE 102
-----------------------------------------------------
City | LAUDERDALE LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33319-5811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-722-6400
-----------------------------------------------------
Fax | 954-735-1958
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4800 N STATE ROAD 7 SUITE 102
-----------------------------------------------------
City | LAUDERDALE LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33319-5811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-722-6400
-----------------------------------------------------
Fax | 954-735-1958
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD OF DIRECTORS PRESIDENT
-----------------------------------------------------
Name | CRAIG LILIENTHAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-722-6400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------