Provider Demographics
NPI:1417491820
Name:CELEBRATE LIFE RECOVERY CENTER PHASE II, LLC
Entity Type:Organization
Organization Name:CELEBRATE LIFE RECOVERY CENTER PHASE II, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ONBOARDING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KELI
Authorized Official - Middle Name:
Authorized Official - Last Name:KORNMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-672-8345
Mailing Address - Street 1:4955 NW 84TH RD
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-1973
Mailing Address - Country:US
Mailing Address - Phone:954-951-6005
Mailing Address - Fax:954-951-6006
Practice Address - Street 1:6043 KIMBERLY BLVD STE U
Practice Address - Street 2:
Practice Address - City:NORTH LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33068-2826
Practice Address - Country:US
Practice Address - Phone:954-951-6005
Practice Address - Fax:954-951-6006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility