Provider Demographics
NPI:1710457783
Name:IMMERSION RESIDENTIAL LLC
Entity Type:Organization
Organization Name:IMMERSION RESIDENTIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-634-4425
Mailing Address - Street 1:900 N CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 N CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426
Practice Address - Country:US
Practice Address - Phone:877-831-2533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility