1356738132 NPI number — RECOVERY VILLAGE AT PALMER LAKE, LLC

Table of content: (NPI 1356738132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356738132 NPI number — RECOVERY VILLAGE AT PALMER LAKE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RECOVERY VILLAGE AT PALMER LAKE, 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:
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:
1356738132
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 SE THIRD AVE, SUITE 1800
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33394
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
754-300-3120
Provider Business Mailing Address Fax Number:
888-919-4431

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
443 HIGHWAY 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALMER LAKE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80133-9003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-481-1800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SURUJON
Authorized Official First Name:
BELINA
Authorized Official Middle Name:
Authorized Official Title or Position:
LICENSING & CONTRACTING DIRECTOR
Authorized Official Telephone Number:
754-300-3120

Provider Taxonomy Codes

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

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





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