Provider Demographics
NPI:1558872614
Name:PALM DETOX, INC
Entity Type:Organization
Organization Name:PALM DETOX, INC
Other - Org Name:PALM DETOX, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:NIZNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-494-5796
Mailing Address - Street 1:1515 NW 167TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5106
Mailing Address - Country:US
Mailing Address - Phone:786-923-3376
Mailing Address - Fax:305-930-7437
Practice Address - Street 1:5455 CONNECTICUT AVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-1215
Practice Address - Country:US
Practice Address - Phone:855-494-5796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-17
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility