Provider Demographics
NPI:1851729982
Name:GREENLIFE INTENSIVE OUTPATIENT PROGRAM LLC
Entity Type:Organization
Organization Name:GREENLIFE INTENSIVE OUTPATIENT PROGRAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ZVI
Authorized Official - Middle Name:AHARON
Authorized Official - Last Name:ITZCHAKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-304-6922
Mailing Address - Street 1:1601 N PALM AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-3240
Mailing Address - Country:US
Mailing Address - Phone:954-304-6922
Mailing Address - Fax:
Practice Address - Street 1:1601 N PALM AVE STE 106
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-3240
Practice Address - Country:US
Practice Address - Phone:954-854-3053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty