Basic Information
| Provider Information | |||||||||
| NPI: | 1780327403 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FATHER FLANAGAN'S BOYS TOWN FLORIDA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1655 PALM BEACH LAKES BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334012203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1561612604 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12983 SOUTHERN BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOXAHATCHEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334709254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616126049 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2022 | ||||||||
| LastUpdateDate: | 04/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | HEMINGS | ||||||||
| AuthorizedOfficialFirstName: | ALICE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5616126049 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FATHER FLANAGAN'S BOYS TOWN FLORIDA, INC | ||||||||
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| NPICertificationDate: | 04/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 011708803 | 05 | FL | MEDICAID |