Provider Demographics
NPI:1932262482
Name:G & G HOLISTIC ADDICTION TREATMENT PROGRAM
Entity Type:Organization
Organization Name:G & G HOLISTIC ADDICTION TREATMENT PROGRAM
Other - Org Name:HOLISTIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDFARB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-945-8384
Mailing Address - Street 1:1590 NE 162ND ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-4759
Mailing Address - Country:US
Mailing Address - Phone:305-945-8384
Mailing Address - Fax:
Practice Address - Street 1:1590 NE 162ND ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-4759
Practice Address - Country:US
Practice Address - Phone:305-945-8384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1113AD165001324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1113AD165001OtherSTATE LICENSE