Provider Demographics
NPI:1144974627
Name:THE ICLT SUMMER PLACE INC
Entity type:Organization
Organization Name:THE ICLT SUMMER PLACE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO- DIRECTOR /PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAUREL
Authorized Official - Middle Name:
Authorized Official - Last Name:NOTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-778-9564
Mailing Address - Street 1:350 ALADDIN ST
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-3533
Mailing Address - Country:US
Mailing Address - Phone:305-769-9438
Mailing Address - Fax:
Practice Address - Street 1:350 ALADDIN ST
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-3533
Practice Address - Country:US
Practice Address - Phone:305-769-9438
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686464396Medicaid