Provider Demographics
NPI:1447545488
Name:MIAMI OUTPATIENT DETOX
Entity type:Organization
Organization Name:MIAMI OUTPATIENT DETOX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:IANNUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-789-9034
Mailing Address - Street 1:175 SW 7TH ST
Mailing Address - Street 2:SUITE 1102
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-2992
Mailing Address - Country:US
Mailing Address - Phone:800-990-0340
Mailing Address - Fax:
Practice Address - Street 1:175 SW 7TH ST
Practice Address - Street 2:SUITE 1102
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-2992
Practice Address - Country:US
Practice Address - Phone:800-990-0340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-17
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty