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General NPI Number Information
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NPI Number | 1417439282
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Entity Type | Organization
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Legal Business Name | NEW LIFE 360 INC
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Dates
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Enumeration Date | 08/29/2018
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Last Update Date | 10/30/2019
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Provider Practice Location Address
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Address Line | 1047 E BRANDON BLVD
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City | BRANDON
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State | FL
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Zip | 33511-5515
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Country | US
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Telephone | 813-548-1166
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Fax |
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Provider Business Mailing Address
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Address Line | 1047 E BRANDON BLVD
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City | BRANDON
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State | FL
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Zip | 33511-5515
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Country | US
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Telephone | 813-548-1166
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | SHERRY BRADLEY
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Credential | LCSW
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Telephone | 734-658-5055
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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