MEDICARE: GREENLIFE INTENSIVE OUTPATIENT PROGRAM 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
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1851729982
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREENLIFE INTENSIVE OUTPATIENT PROGRAM LLC

Provider Business Mailing Address
First Line	:	1601 N PALM AVE STE 106
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33026-3240
Country	:	US
Telephone Number	:	954-304-6922
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 N PALM AVE STE 106
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33026-3240
Country	:	US
Telephone Number	:	954-854-3053
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ZVI AHARON ITZCHAKI
Credential	:
Telephone Number	:	954-304-6922

Provider Enumeration Date	:	10/29/2013
Last Update Date	:	02/03/2021

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