=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952784183
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMA VISTA RECOVERY AND WELLNESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2015
-----------------------------------------------------
Last Update Date | 07/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7664 S US HIGHWAY 1
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34952-2315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-461-8833
-----------------------------------------------------
Fax | 772-461-8872
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7664 S US HIGHWAY 1
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34952-2315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-461-8833
-----------------------------------------------------
Fax | 772-461-8872
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. GERALD A DIBARTOLOMEO JR.
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 772-461-8833
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------