1306211149 NPI number — 314 GROVE NECK ROAD OPCO, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306211149 NPI number — 314 GROVE NECK ROAD OPCO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
314 GROVE NECK ROAD OPCO, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306211149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2201 RENAISSANCE BLVD FL 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KING OF PRUSSIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19406-2709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-994-2900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
RECOVERY CENTERS OF AMERICA AT BRACEBRIDGE HALL
Provider Second Line Business Practice Location Address:
314 GROVE NECK RD
Provider Business Practice Location Address City Name:
EARLEVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21919-3008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-275-6200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/04/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CRUZ
Authorized Official First Name:
SERGE
Authorized Official Middle Name:
Authorized Official Title or Position:
CORP DIR PATIENT ACCOUNTS
Authorized Official Telephone Number:
610-427-9434

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)