MEDICARE: WHITE OAK 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	:	1710513593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITE OAK RECOVERY CENTER LLC

Provider Business Mailing Address
First Line	:	4009 MASONBORO LOOP RD
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28409-3640
Country	:	US
Telephone Number	:	704-450-2117
Fax Number	:

Provider Business Practice Location Address
First Line	:	7838 VANTAGE AVE
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91605-2408
Country	:	US
Telephone Number	:	704-450-2117
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DUSTIN JOHNSON
Credential	:
Telephone Number	:	704-450-2117

Provider Enumeration Date	:	03/12/2020
Last Update Date	:	11/27/2024

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Directions to “WHITE OAK RECOVERY CENTER LLC ” Practice Location

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