MEDICARE: LUCIENNE RESIDENTIAL SERVICES, INC.

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1811476534
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUCIENNE RESIDENTIAL SERVICES, INC.

Provider Business Mailing Address
First Line	:	4882 SW 159TH AVE
Second Line	:
City	:	MIRAMAR
State	:	FL
Zip	:	33027-5645
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9179 FOUNTAIN RD
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-4735
Country	:	US
Telephone Number	:	508-846-2747
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DIEUFENE SYLVAIN
Credential	:
Telephone Number	:	508-846-2747

Provider Enumeration Date	:	08/13/2018
Last Update Date	:	08/13/2018

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