Provider Demographics
NPI:1932598851
Name:MIVIP BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:MIVIP BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:
Authorized Official - Last Name:VERBUKH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-392-3341
Mailing Address - Street 1:398 CAMINO GARDENS BLVD
Mailing Address - Street 2:102
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-5827
Mailing Address - Country:US
Mailing Address - Phone:561-392-3341
Mailing Address - Fax:561-829-5482
Practice Address - Street 1:3475 SHERIDAN ST
Practice Address - Street 2:101
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-3663
Practice Address - Country:US
Practice Address - Phone:855-496-4847
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIVIP MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Single Specialty