Provider Demographics
NPI:1225486202
Name:ORIGINS OF HOPE LLC
Entity Type:Organization
Organization Name:ORIGINS OF HOPE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAJARAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-272-6723
Mailing Address - Street 1:5511 S CONGRESS AVE STE 125
Mailing Address - Street 2:
Mailing Address - City:ATLANTIS
Mailing Address - State:FL
Mailing Address - Zip Code:33462-1140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5511 S CONGRESS AVE STE 125
Practice Address - Street 2:
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-1140
Practice Address - Country:US
Practice Address - Phone:561-304-4673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility