Healthcare Provider Details

I. General information

NPI: 1225494529
Provider Name (Legal Business Name): ROCKIN RECOVERY LIFE SKILLS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2016
Last Update Date: 01/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 NE 5TH AVE
DELRAY BEACH FL
33483-5530
US

IV. Provider business mailing address

PO BOX 6542
DELRAY BEACH FL
33482-6542
US

V. Phone/Fax

Practice location:
  • Phone: 561-255-3573
  • Fax: 561-808-7394
Mailing address:
  • Phone: 561-255-3573
  • Fax: 561-808-7394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1550AD185301
License Number StateFL

VIII. Authorized Official

Name: KELI KORNMILLER
Title or Position: SENIOR CREDENTIALING SPECIALIST
Credential:
Phone: 561-672-8345