Provider Demographics
NPI:1912540766
Name:BANYAN PALM SPRINGS LLC
Entity Type:Organization
Organization Name:BANYAN PALM SPRINGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:YATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-533-7705
Mailing Address - Street 1:225 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-4319
Mailing Address - Country:US
Mailing Address - Phone:888-879-4975
Mailing Address - Fax:
Practice Address - Street 1:73771 DINAH SHORE DR
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-0860
Practice Address - Country:US
Practice Address - Phone:888-879-4975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-24
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility