MEDICARE: INSPIRE YOUTH ACADEMY 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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1598161788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INSPIRE YOUTH ACADEMY LLC

Provider Business Mailing Address
First Line	:	24 SW 10TH ST
Second Line	:	UNIT A
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33315-1272
Country	:	US
Telephone Number	:	813-644-7753
Fax Number	:	888-482-2405

Provider Business Practice Location Address
First Line	:	757 SE 17TH ST
Second Line	:	#328
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33316-2960
Country	:	US
Telephone Number	:	813-644-7753
Fax Number	:	888-482-2405

Authorized Official
Title or Position	:	MEMBER
Name	:	MR. CHRISTOPHER WALSH
Credential	:
Telephone Number	:	813-644-7753

Provider Enumeration Date	:	11/14/2014
Last Update Date	:	11/14/2014

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