Provider Demographics
NPI:1023456597
Name:LA AMISTAD RESIDENTIAL TREATMENT CENTER INC
Entity type:Organization
Organization Name:LA AMISTAD RESIDENTIAL TREATMENT CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-370-0111
Mailing Address - Street 1:6601 CENTRAL FLORIDA PKWY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-8064
Mailing Address - Country:US
Mailing Address - Phone:407-264-0111
Mailing Address - Fax:407-264-7745
Practice Address - Street 1:6601 CENTRAL FLORIDA PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32821-8064
Practice Address - Country:US
Practice Address - Phone:407-264-0111
Practice Address - Fax:407-264-7745
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAAMISTAD RESIDENTIAL TREATMENT CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4498283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE2MOtherBCBS