Provider Demographics
NPI:1104367085
Name:RESTORE HOPE OF JENSEN BEACH, LLC
Entity Type:Organization
Organization Name:RESTORE HOPE OF JENSEN BEACH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KAHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-742-2925
Mailing Address - Street 1:3300 NE SUGARHILL AVE
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-3700
Mailing Address - Country:US
Mailing Address - Phone:772-444-7388
Mailing Address - Fax:772-742-2925
Practice Address - Street 1:3300 NE SUGARHILL AVE
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-3700
Practice Address - Country:US
Practice Address - Phone:772-444-7388
Practice Address - Fax:772-742-2925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4381356911601261QR0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care