=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215384433
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TREE OF LIFE BEHAVIORAL HEALTHCARE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2016
-----------------------------------------------------
Last Update Date | 05/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8785 SW 165TH AVE STE 200-2001
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33193-5826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-347-2737
-----------------------------------------------------
Fax | 786-347-2728
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8785 SW 165TH AVE STE 200-2001
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33193-5826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-347-2737
-----------------------------------------------------
Fax | 786-347-2728
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. MARTHA R JIMENEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-365-9031
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------