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General NPI Number Information
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NPI Number | 1962117101
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Entity Type | Organization
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Legal Business Name | AUTHENTIC LIVING CENTER, LLC
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Dates
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Enumeration Date | 01/23/2023
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Last Update Date | 04/26/2023
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Provider Practice Location Address
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Address Line | 25400 US HIGHWAY 19 N STE 156
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City | CLEARWATER
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State | FL
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Zip | 33763-2150
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Country | US
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Telephone | 727-480-0107
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Fax | 727-499-7555
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Provider Business Mailing Address
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Address Line | 25400 US HIGHWAY 19 N STE 156
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City | CLEARWATER
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State | FL
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Zip | 33763-2150
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Country | US
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Telephone | 727-480-0107
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Fax | 727-499-7555
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Authorized Official
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Title or Position | CEO/PROVIDER
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Name | KARMIVIS SANTIAGO
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Credential | LMHC
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Telephone | 727-480-0107
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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