Provider Demographics
NPI:1497533343
Name:MIDWEST DETOX AT AMBROSIA LLC MIDWEST DETOX
Entity Type:Organization
Organization Name:MIDWEST DETOX AT AMBROSIA LLC MIDWEST DETOX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANESH
Authorized Official - Middle Name:
Authorized Official - Last Name:ALAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-390-0042
Mailing Address - Street 1:222 PICADILLY ST
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BCH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-6017
Mailing Address - Country:US
Mailing Address - Phone:561-578-8600
Mailing Address - Fax:561-578-8601
Practice Address - Street 1:2010 PONCE DE LEON AVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-6040
Practice Address - Country:US
Practice Address - Phone:561-578-8585
Practice Address - Fax:561-429-6690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-20
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility