Provider Demographics
NPI:1700245719
Name:SOUTH OCEAN RECOVERY
Entity Type:Organization
Organization Name:SOUTH OCEAN RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KELI
Authorized Official - Middle Name:
Authorized Official - Last Name:KORNMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-672-8345
Mailing Address - Street 1:7731 N MILITARY TRL STE 1
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33410-7430
Mailing Address - Country:US
Mailing Address - Phone:561-425-5343
Mailing Address - Fax:
Practice Address - Street 1:1732 S CONGRESS AVE STE 354
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461-2140
Practice Address - Country:US
Practice Address - Phone:561-425-5343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
FL1550AD332201261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251S00000XAgenciesCommunity/Behavioral Health