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General NPI Number Information
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NPI Number | 1619422763
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Entity Type | Organization
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Legal Business Name | RESTORE HOPE OF JENSEN BEACH LLC
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Dates
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Enumeration Date | 08/18/2016
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Last Update Date | 07/23/2019
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Provider Practice Location Address
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Address Line | 1320 SE FEDERAL HWY STE 105
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City | STUART
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State | FL
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Zip | 34994-3409
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Country | US
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Telephone | 772-444-7388
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Fax | 772-444-7388
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Provider Business Mailing Address
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Address Line | 1320 SE FEDERAL HWY STE 105
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City | STUART
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State | FL
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Zip | 34994-3409
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Country | US
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Telephone | 772-444-7388
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Fax | 772-444-7388
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | JOSE JUAN DIAZ
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Credential | DO
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Telephone | 772-444-7388
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR0800X
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Taxonomy Name | Recovery Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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