MEDICARE: RECOVER UNDERCOVER 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	177F00000X	Lodging Provider
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1730956293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RECOVER UNDERCOVER LLC

Provider Business Mailing Address
First Line	:	1600 CALEBS PATH EXT STE 122
Second Line	:
City	:	HAUPPAUGE
State	:	NY
Zip	:	11788-5224
Country	:	US
Telephone Number	:	631-994-1075
Fax Number	:	631-350-0293

Provider Business Practice Location Address
First Line	:	1600 CALEBS PATH EXT STE 122
Second Line	:
City	:	HAUPPAUGE
State	:	NY
Zip	:	11788-5224
Country	:	US
Telephone Number	:	631-994-1075
Fax Number	:	631-350-0293

Authorized Official
Title or Position	:	OWNER
Name	:	MS. CATHY RANDOLPH
Credential	:	NP
Telephone Number	:	631-546-8849

Provider Enumeration Date	:	12/05/2023
Last Update Date	:	12/11/2025

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