Provider Demographics
NPI:1568605137
Name:L.I.L.A.C. OF JUPITER/PALM BEACH, LLC
Entity Type:Organization
Organization Name:L.I.L.A.C. OF JUPITER/PALM BEACH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-221-0190
Mailing Address - Street 1:1630 N US HIGHWAY 1
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:TEQUESTA
Mailing Address - State:FL
Mailing Address - Zip Code:33469-3208
Mailing Address - Country:US
Mailing Address - Phone:561-575-6211
Mailing Address - Fax:
Practice Address - Street 1:1630 N US HIGHWAY 1 SUITE 1
Practice Address - Street 2:SUITE ONE
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33469-3208
Practice Address - Country:US
Practice Address - Phone:561-575-6211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility