Provider Demographics
NPI:1023580586
Name:PEARL OF THE SEA RETREAT, LLC
Entity Type:Organization
Organization Name:PEARL OF THE SEA RETREAT, LLC
Other - Org Name:PEARL OF THE SEA RETREAT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-909-5283
Mailing Address - Street 1:7601 A1A S
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-8206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7601 A1A S
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-8206
Practice Address - Country:US
Practice Address - Phone:617-909-5283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-21
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility