Provider Demographics
NPI:1043378730
Name:ADVANCED BEHAVIORAL HEALTH CENTER PA
Entity type:Organization
Organization Name:ADVANCED BEHAVIORAL HEALTH CENTER PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:EDGARDO
Authorized Official - Last Name:TORRES RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:352-742-8300
Mailing Address - Street 1:1799 SALK AVE
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4311
Mailing Address - Country:US
Mailing Address - Phone:352-744-8300
Mailing Address - Fax:352-742-8305
Practice Address - Street 1:1799 SALK AVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4311
Practice Address - Country:US
Practice Address - Phone:352-744-8300
Practice Address - Fax:352-742-8305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6879Medicare PIN
FLDE0763Medicare PIN