MEDICARE: SOUTH BEACH DETOX LLC

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	324500000X	Substance Abuse Rehabilitation Facility	001957	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	001957	OTHER	FL	DCF STATE LICENSE
2	PROV-001957	OTHER	FL	DCF PROVISIONAL LICENSE NUMBER

General Provider Information

NPI Number	:	1043700578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH BEACH DETOX LLC

Provider Business Mailing Address
First Line	:	16400 NW 2ND AVENUE SUITE 200
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33169-6035
Country	:	US
Telephone Number	:	305-430-6040
Fax Number	:	305-705-4269

Provider Business Practice Location Address
First Line	:	85 NW 168TH STREET
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33169-6053
Country	:	US
Telephone Number	:	305-430-6040
Fax Number	:	305-705-4269

Authorized Official
Title or Position	:	OWNER
Name	:	DONNA HURWIT
Credential	:	ARNP
Telephone Number	:	305-992-8117

Provider Enumeration Date	:	05/10/2018
Last Update Date	:	08/12/2021

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Directions to “SOUTH BEACH DETOX LLC ” Practice Location

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