MEDICARE: SEQUEL TSI OF FLORIDA, 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	3245S0500X	Children's Substance Abuse Rehabilitation Facility
2	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1699222026
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEQUEL TSI OF FLORIDA, LLC

Provider Business Mailing Address
First Line	:	9680 FAIRGROUND RD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-3528
Country	:	US
Telephone Number	:	561-333-0664
Fax Number	:

Provider Business Practice Location Address
First Line	:	9680 FAIRGROUND RD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-3528
Country	:	US
Telephone Number	:	561-333-0664
Fax Number	:

Authorized Official
Title or Position	:	SVP OPERATIONS
Name	:	MR. KENNY ROBERTS
Credential	:
Telephone Number	:	256-880-3339

Provider Enumeration Date	:	09/01/2016
Last Update Date	:	09/01/2016

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