MEDICARE: THE GRAPEVINE HOUSE, 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	1550AD290601	FL

General Provider Information

NPI Number	:	1417203175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE GRAPEVINE HOUSE, LLC

Provider Business Mailing Address
First Line	:	381 NE 5TH AVE
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33483-5532
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	381 NE 5TH AVE
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33483-5532
Country	:	US
Telephone Number	:	754-201-2265
Fax Number	:

Authorized Official
Title or Position	:	ACCOUNT SPECIALIST
Name	:	JOSE FLORES
Credential	:
Telephone Number	:	754-201-2265

Provider Enumeration Date	:	07/31/2012
Last Update Date	:	07/31/2012

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Directions to “THE GRAPEVINE HOUSE, LLC ” Practice Location

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