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General NPI Number Information
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NPI Number | 1750702122
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Entity Type | Organization
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Legal Business Name | SEVENTY SEVEN RECOVERY INC
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Dates
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Enumeration Date | 01/02/2014
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Last Update Date | 01/02/2014
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Provider Practice Location Address
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Address Line | 315 11TH ST
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City | WEST PALM BEACH
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State | FL
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Zip | 33401-3321
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Country | US
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Telephone | 561-355-1223
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Fax | 561-828-3158
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Provider Business Mailing Address
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Address Line | 315 11TH ST
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City | WEST PALM BEACH
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State | FL
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Zip | 33401-3321
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Country | US
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Telephone | 561-355-1223
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Fax | 561-828-3158
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Authorized Official
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Title or Position | CEO
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Name | MR. PABLO ARNULFO LOPEZ DE LEON
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Credential |
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Telephone | 561-355-1223
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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 | 1550AD183801
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License Number State | FL
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