MEDICARE: HOLISTIX BY THE SEA, 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	1706AD706002	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1706AD706002	OTHER	FL	FLORIDA STATE DCF LICENSE

General Provider Information

NPI Number	:	1518358803
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLISTIX BY THE SEA, LLC

Provider Business Mailing Address
First Line	:	803 NW 2ND AVE
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33060-5604
Country	:	US
Telephone Number	:	877-872-7730
Fax Number	:

Provider Business Practice Location Address
First Line	:	3217 NE 9TH ST
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33062-4069
Country	:	US
Telephone Number	:	954-491-3413
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	ALAN TYLER
Credential	:
Telephone Number	:	954-899-4131

Provider Enumeration Date	:	02/09/2015
Last Update Date	:	02/09/2015

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