MEDICARE: COASTAL GARDENS RECOVERY CENTER 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	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1598509812
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL GARDENS RECOVERY CENTER LLC

Provider Business Mailing Address
First Line	:	3625 HIDDEN TREE LN
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-8388
Country	:	US
Telephone Number	:	239-666-1847
Fax Number	:

Provider Business Practice Location Address
First Line	:	3625 HIDDEN TREE LN
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-8388
Country	:	US
Telephone Number	:	239-666-1847
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	RAANAN DVIR
Credential	:
Telephone Number	:	203-606-5984

Provider Enumeration Date	:	06/21/2024
Last Update Date	:	06/21/2024

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