MEDICARE: SOUTHERN PALMS OASIS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1043676893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN PALMS OASIS, INC.

Provider Business Mailing Address
First Line	:	3936 LOWSON BLVD
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33445-5651
Country	:	US
Telephone Number	:	561-632-8712
Fax Number	:

Provider Business Practice Location Address
First Line	:	3936 LOWSON BLVD
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33445-5651
Country	:	US
Telephone Number	:	561-632-8712
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT, CEO, CFO
Name	:	MR. NEIL SIMON
Credential	:
Telephone Number	:	561-632-8712

Provider Enumeration Date	:	01/10/2016
Last Update Date	:	01/10/2016

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