Provider Demographics
NPI:1790163319
Name:SPENCER RECOVERY CENTERS FLORIDA, INC.
Entity Type:Organization
Organization Name:SPENCER RECOVERY CENTERS FLORIDA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:KANUTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-315-9225
Mailing Address - Street 1:PO BOX 9296
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92652-7261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:189 SAN MARCO AVE
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-2733
Practice Address - Country:US
Practice Address - Phone:800-334-0394
Practice Address - Fax:949-313-5222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-14
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
323P00000X
FL0755AD237401324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS5BOtherFLORIDA BLUE
FLE5NOtherFLORIDA BLUE