Healthcare Provider Details

I. General information

NPI: 1306539226
Provider Name (Legal Business Name): CHOICE RECOVERY HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2023
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BIDDLE AVE STE 101
NEWARK DE
19702-3982
US

IV. Provider business mailing address

9123 OLD ANNAPOLIS RD STE 203&204
COLUMBIA MD
21045-1953
US

V. Phone/Fax

Practice location:
  • Phone: 410-505-8605
  • Fax: 240-770-0436
Mailing address:
  • Phone: 410-505-8605
  • Fax: 240-770-0436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TRISTAN J SHOCKLEY
Title or Position: CEO/OWNER
Credential: MD
Phone: 202-489-1125