MEDICARE: FLOURISHING FOUNDATIONS RECOVERY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1265168942
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLOURISHING FOUNDATIONS RECOVERY, LLC

Provider Business Mailing Address
First Line	:	11507 MOUNTAIN CLIMB
Second Line	:
City	:	HELOTES
State	:	TX
Zip	:	78023-3450
Country	:	US
Telephone Number	:	805-796-1253
Fax Number	:	772-206-3292

Provider Business Practice Location Address
First Line	:	6707 W HAUSMAN RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-4173
Country	:	US
Telephone Number	:	805-796-1253
Fax Number	:	210-783-1596

Authorized Official
Title or Position	:	OWNER
Name	:	NICHOLAS DI MARTINO
Credential	:
Telephone Number	:	805-796-1253

Provider Enumeration Date	:	07/26/2022
Last Update Date	:	01/31/2024

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