Provider Demographics
NPI:1881966190
Name:NEW LIFE ADDICTION TREATMENT CENTER
Entity type:Organization
Organization Name:NEW LIFE ADDICTION TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO & MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLEDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-919-1422
Mailing Address - Street 1:905 E PRIMA VISTA BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-2359
Mailing Address - Country:US
Mailing Address - Phone:855-337-8500
Mailing Address - Fax:772-337-8505
Practice Address - Street 1:905 E PRIMA VISTA BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-2359
Practice Address - Country:US
Practice Address - Phone:855-337-8500
Practice Address - Fax:772-337-8505
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEURODIAGNOSTICS OF STUART, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1956AD877101324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF-07905Medicare UPIN