Provider Demographics
NPI:1245736057
Name:STONE LOVE RETREAT LLC
Entity Type:Organization
Organization Name:STONE LOVE RETREAT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAINT LUC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-713-4819
Mailing Address - Street 1:3125 FORTUNE WAY STE 13
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-8783
Mailing Address - Country:US
Mailing Address - Phone:561-713-4819
Mailing Address - Fax:
Practice Address - Street 1:3125 FORTUNE WAY STE 13
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-8783
Practice Address - Country:US
Practice Address - Phone:561-713-4819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1005270261QR0405X
324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility