Healthcare Provider Details

I. General information

NPI: 1275981243
Provider Name (Legal Business Name): COCONUT GROVE RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2016
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15291 NW 60TH AVE STE 200-201
MIAMI LAKES FL
33014-8590
US

IV. Provider business mailing address

15291 NW 60TH AVE STE 200/201
MIAMI LAKES FL
33014-8590
US

V. Phone/Fax

Practice location:
  • Phone: 952-234-2469
  • Fax: 954-204-0464
Mailing address:
  • Phone: 954-234-2469
  • Fax: 954-204-0464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME43252
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateFL

VIII. Authorized Official

Name: CATHY A PICILLO
Title or Position: OFFICE MGR
Credential:
Phone: 954-234-2469