Provider Demographics
NPI:1619422763
Name:RESTORE HOPE OF JENSEN BEACH LLC
Entity Type:Organization
Organization Name:RESTORE HOPE OF JENSEN BEACH LLC
Other - Org Name:RESTORE HOPE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:JUAN
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:772-444-7388
Mailing Address - Street 1:1320 SE FEDERAL HWY STE 105
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-3409
Mailing Address - Country:US
Mailing Address - Phone:772-444-7388
Mailing Address - Fax:772-444-7388
Practice Address - Street 1:1320 SE FEDERAL HWY STE 105
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3409
Practice Address - Country:US
Practice Address - Phone:772-444-7388
Practice Address - Fax:772-444-7388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care