is a Addiction Medicine in Port St Lucie, Florida. practices all healthcare services and medical treatments related to Addiction Medicine. The NPI Number for is 1982716353. The last update date is .
's current location address is 1420 Sw Saint Lucie West Blvd, Port St Lucie, Florida. You can contact this provider via phone number 8887695408 and fax number 7723246440. The mailing address for is 1420 Sw Saint Lucie West Blvd, Port St Lucie, Florida. To know further, please read the information below!
Provider Profile Detail
| Provider Name | |
|---|---|
| Address | 1420 Sw Saint Lucie West Blvd, Port St Lucie, Florida |
| Phone Number | 8887695408 |
| Fax Number | 7723246440 |
| Sole Proprietor | -- |
| Credentials | -- |
NPI Number Detail
| NPI Number | 1982716353 |
|---|---|
| Provider Enumeration Date | |
| Last Updated Date |
Provider Mailing Address Detail
| Address | 1420 Sw Saint Lucie West Blvd |
|---|---|
| City | Port St Lucie |
| State | Florida (FL) |
| Post Code | 349861709 |
| Phone Number | 8887695408 |
| Fax Number | 7723246440 |
Provider's Primary Taxonomy Detail
| Speciality | Addiction Medicine |
|---|---|
| Taxonomy | 2084A0401X |
| Licence No | PA9101894 |
|
Definition: A doctor of osteopathy board eligible/certified in the field of Psychiatry by the American Osteopathic Board of Neurology and Psychiatry is able to obtain a Certificate of Added Qualifications in the field of Addiction Medicine |
|
Provider's Other Legacy Identifiers
| Identifier | Identifier Type | Identifier State | Identifier Issuer |
|---|---|---|---|
| P62437 | MEDICARE UPIN | ||
| VAUPP | FL | BCBS PROVIDER NUMBER | |
| 12697304 | CAQH |
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