Basic Information
| Provider Information | |||||||||
| NPI: | 1417435165 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOLACE BEHAVIORAL HEALTH PSYCHIATRIC & SUBSTANCE ABUSE IOP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17222 HOSPITAL BLVD STE 226 | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346018925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526785550 | ||||||||
| FaxNumber: | 3526785551 | ||||||||
| Practice Location | |||||||||
| Address1: | 8449 COBB RD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346018704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526785550 | ||||||||
| FaxNumber: | 3526785551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2018 | ||||||||
| LastUpdateDate: | 08/04/2018 | ||||||||
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| AuthorizedOfficialLastName: | SPADAFORA | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3526785550 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOLACE BEHAVIORAL HEALTH, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 324500000X | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 010023100 | 05 | FL | MEDICAID | GW088A | 01 | FL | MEDICARE | OTHER |