1457658536 NPI number — WELLINGTON RETREAT, INC.

Table of content: (NPI 1457658536)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457658536 NPI number — WELLINGTON RETREAT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLINGTON RETREAT, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAMILY CENTER FOR RECOVERY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457658536
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7051 SEACREST BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANTANA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33462-5139
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-296-5288
Provider Business Mailing Address Fax Number:
561-623-0089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7051 SEACREST BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANTANA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33462-5139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-296-5288
Provider Business Practice Location Address Fax Number:
561-623-0089
Provider Enumeration Date:
02/25/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BAZZANO
Authorized Official First Name:
JAYNE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
DIRECTOR/BILLING/CONTRACTING
Authorized Official Telephone Number:
954-732-8299

Provider Taxonomy Codes

  • Taxonomy code: 323P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 324500000X , with the licence number: 1550AD780401 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)