=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932542941
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW LIFE BEHAVIORAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2013
-----------------------------------------------------
Last Update Date | 04/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 725 N HIGHWAY A1A SUITE B106
-----------------------------------------------------
City | JUPITER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33477-4571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-329-3642
-----------------------------------------------------
Fax | 561-747-0258
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 725 N HIGHWAY A1A SUITE B106
-----------------------------------------------------
City | JUPITER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33477-4571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-329-3642
-----------------------------------------------------
Fax | 561-747-0258
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. JOHN C. PROFERA
-----------------------------------------------------
Credential | ARNP
-----------------------------------------------------
Telephone | 561-329-3642
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 2966762
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------