=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770953168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITA NOVA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2015
-----------------------------------------------------
Last Update Date | 01/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3111 S DIXIE HWY STE 243
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33405-1548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-689-0035
-----------------------------------------------------
Fax | 561-689-0806
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3111 S DIXIE HWY STE 243
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33405-1548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-689-0035
-----------------------------------------------------
Fax | 561-689-0806
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATIONS OFFICER
-----------------------------------------------------
Name | GEORGE SHOPLAND
-----------------------------------------------------
Credential | M.ED
-----------------------------------------------------
Telephone | 561-689-0035
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------