Provider Demographics
NPI:1750718714
Name:TLC RECOVERY CENTER OF S FLORIDA, LLC
Entity type:Organization
Organization Name:TLC RECOVERY CENTER OF S FLORIDA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GEDALE
Authorized Official - Middle Name:
Authorized Official - Last Name:FENSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-725-8790
Mailing Address - Street 1:2901 W CYPRESS CREEK RD STE 123
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-1732
Mailing Address - Country:US
Mailing Address - Phone:954-915-7444
Mailing Address - Fax:954-206-0372
Practice Address - Street 1:2901 W CYPRESS CREEK RD STE 123
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-1732
Practice Address - Country:US
Practice Address - Phone:954-915-7444
Practice Address - Fax:954-206-0372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084P0800X, 261QA0600X, 261QR0405X, 323P00000X
FL1706AD153701324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL569681OtherTHE JOINT COMMISSION