MEDICARE: SUNSHINE STATE TREATMENT CENTER, 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	5001	FL

General Provider Information

NPI Number	:	1063967032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNSHINE STATE TREATMENT CENTER, LLC

Provider Business Mailing Address
First Line	:	900 N FEDERAL HWY STE 104
Second Line	:
City	:	LAKE PARK
State	:	FL
Zip	:	33403-2856
Country	:	US
Telephone Number	:	561-876-5100
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 N FEDERAL HWY STE 104
Second Line	:
City	:	LAKE PARK
State	:	FL
Zip	:	33403-2856
Country	:	US
Telephone Number	:	561-876-5100
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SIGRID EZSA ALLEN
Credential	:	MS,RIMHC
Telephone Number	:	561-876-5100

Provider Enumeration Date	:	08/19/2016
Last Update Date	:	07/21/2022

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