Provider Demographics
NPI:1568877561
Name:MIDDLE RIVER SOBER LIVING
Entity Type:Organization
Organization Name:MIDDLE RIVER SOBER LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KEANE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:908-783-3923
Mailing Address - Street 1:811 SE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-8405
Mailing Address - Country:US
Mailing Address - Phone:954-560-5238
Mailing Address - Fax:
Practice Address - Street 1:101 SE 26TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-3972
Practice Address - Country:US
Practice Address - Phone:954-560-5238
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-27
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10D2076037324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D2076037OtherFL STATE CLIA LICENSE