MEDICARE: BLUE SKY TREATMENT

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	1706AD953702	FL

General Provider Information

NPI Number	:	1942604004
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE SKY TREATMENT

Provider Business Mailing Address
First Line	:	5360 N FEDERAL HWY
Second Line	:
City	:	LIGHTHOUSE POINT
State	:	FL
Zip	:	33064-7068
Country	:	US
Telephone Number	:	754-222-6884
Fax Number	:	954-746-8232

Provider Business Practice Location Address
First Line	:	5360 N FEDERAL HWY
Second Line	:
City	:	LIGHTHOUSE POINT
State	:	FL
Zip	:	33064-7068
Country	:	US
Telephone Number	:	754-222-6884
Fax Number	:	954-746-8232

Authorized Official
Title or Position	:	OWNER
Name	:	ANDREW FRIIS
Credential	:
Telephone Number	:	754-222-6884

Provider Enumeration Date	:	10/20/2014
Last Update Date	:	10/20/2014

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