MEDICARE: DOMUS LEONUM 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	101YA0400X	Addiction (Substance Use Disorder) Counselor	ME49592	FL

General Provider Information

NPI Number	:	1730546862
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOMUS LEONUM LLC

Provider Business Mailing Address
First Line	:	1551 FORUM PLACE
Second Line	:	BUILDING 400 SUITE D/E
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-5505
Country	:	US
Telephone Number	:	917-528-0694
Fax Number	:

Provider Business Practice Location Address
First Line	:	1551 FORUM PLACE
Second Line	:	BUILDING 400 SUITE D/E
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-5505
Country	:	US
Telephone Number	:	917-528-0694
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ARPANA SHIVDASANI
Credential	:	P.A
Telephone Number	:	917-528-0694

Provider Enumeration Date	:	01/20/2016
Last Update Date	:	01/20/2016

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