1871949388 NPI number — THE RECOVERY VILLAGE MARYLAND, LLC

Table of content: (NPI 1871949388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871949388 NPI number — THE RECOVERY VILLAGE MARYLAND, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE RECOVERY VILLAGE MARYLAND, 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:
1871949388
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 3RD AVE
Provider Second Line Business Mailing Address:
SUITE 1800
Provider Business Mailing Address City Name:
FT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33394-0002
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:
13400 EDGEMEADE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPPER MARLBORO
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
754-300-3120
Provider Business Practice Location Address Fax Number:
888-919-4431
Provider Enumeration Date:
05/13/2016

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: 323P00000X , with the licence number:  16-023 , registered in the state of MD ; 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)





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