Provider Demographics
NPI: | 1467193623 |
---|---|
Name: | SUD FACILITY OPTIMIZATION, LLC |
Entity Type: | Organization |
Organization Name: | SUD FACILITY OPTIMIZATION, LLC |
Other - Org Name: | SUD FAC OPT |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | RESEARCH DIRECTOR |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | JAY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BOULDIN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MBBS, MD, PHD22 |
Authorized Official - Phone: | 321-989-2187 |
Mailing Address - Street 1: | 1030 VENETIAN DR UNIT 202 |
Mailing Address - Street 2: | |
Mailing Address - City: | MELBOURNE |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32904-8466 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 954-260-0104 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1030 VENETIAN DR UNIT 202 |
Practice Address - Street 2: | |
Practice Address - City: | MELBOURNE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32904-8466 |
Practice Address - Country: | US |
Practice Address - Phone: | 954-260-0104 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2022-04-04 |
Last Update Date: | 2022-08-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 163WA0400X | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
No | 207QA0401X | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | Group - Multi-Specialty |
No | 207RA0401X | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | Group - Multi-Specialty |
No | 2084A0401X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | Group - Multi-Specialty |
No | 261QR0405X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | Group - Multi-Specialty |
No | 261QR1100X | Ambulatory Health Care Facilities | Clinic/Center | Research | Group - Multi-Specialty |
No | 324500000X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Group - Multi-Specialty | |
No | 363LA2100X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | Group - Multi-Specialty |
No | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | Group - Multi-Specialty |
No | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health | Group - Multi-Specialty |
No | 363LP2300X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | Group - Multi-Specialty |