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General NPI Number Information
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NPI Number | 1295198208
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Entity Type | Organization
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Legal Business Name | IMMERSION RECOVERY CENTER LLC
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Dates
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Enumeration Date | 03/29/2016
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Last Update Date | 03/29/2016
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Provider Practice Location Address
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Address Line | 1700 W WOOLBRIGHT RD STE 4
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City | BOYNTON BEACH
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State | FL
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Zip | 33426-6346
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Country | US
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Telephone | 561-843-5904
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Fax |
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Provider Business Mailing Address
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Address Line | 1700 W WOOLBRIGHT RD STE 4
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City | BOYNTON BEACH
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State | FL
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Zip | 33426-6346
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | JUSTIN WILLIAM
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Credential |
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Telephone | 561-863-5904
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number |
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License Number State |
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