Provider Demographics
NPI:1952784183
Name:PRIMA VISTA RECOVERY AND WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:PRIMA VISTA RECOVERY AND WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIBARTOLOMEO
Authorized Official - Suffix:JR
Authorized Official - Credentials:CPA
Authorized Official - Phone:772-461-8833
Mailing Address - Street 1:7664 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-2315
Mailing Address - Country:US
Mailing Address - Phone:772-461-8833
Mailing Address - Fax:772-461-8872
Practice Address - Street 1:7664 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-2315
Practice Address - Country:US
Practice Address - Phone:772-461-8833
Practice Address - Fax:772-461-8872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder