Basic Information
| Provider Information | |||||||||
| NPI: | 1548794480 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HONEY LAKE CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13639 ALLAMANDA CIR | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339813911 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1449 NW HONEY LAKE RD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323314069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545369539 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2017 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
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| AuthorizedOfficialLastName: | RAJARAM | ||||||||
| AuthorizedOfficialFirstName: | NICOLA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9542726612 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 324500000X | FL | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.