Provider Demographics
NPI:1073914917
Name:JUPITER MEDICAL CENTER PAVILION, INC.
Entity Type:Organization
Organization Name:JUPITER MEDICAL CENTER PAVILION, INC.
Other - Org Name:LIGHTHOUSE DETOX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEARTFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT, NHA
Authorized Official - Phone:561-263-5090
Mailing Address - Street 1:1230 S OLD DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7205
Mailing Address - Country:US
Mailing Address - Phone:561-263-5090
Mailing Address - Fax:561-263-5730
Practice Address - Street 1:1230 S OLD DIXIE HWY
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7205
Practice Address - Country:US
Practice Address - Phone:561-263-5090
Practice Address - Fax:561-263-5730
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JUPITER MEDICAL CENTER PAVILION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1263096324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105047Medicare PIN