=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396563920
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUCID HEALING CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2024
-----------------------------------------------------
Last Update Date | 10/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3450 NORTHLAKE BLVD STE 110
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33403-1712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-667-3383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3450 NORTHLAKE BLVD STE 110
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33403-1712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-667-3383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MGR
-----------------------------------------------------
Name | ANTHONY CAMAEREI
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 570-242-1768
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------