Healthcare Provider Details

I. General information

NPI: 1740696442
Provider Name (Legal Business Name): OPIATE RECOVERY NETWORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 MARTIN LUTHER KING JR BLVD
ST. PETERSBURG FL
33713
US

IV. Provider business mailing address

502 PASADENA AVE S
ST PETERSBURG FL
33707-2126
US

V. Phone/Fax

Practice location:
  • Phone: 727-527-6200
  • Fax:
Mailing address:
  • Phone: 727-381-9500
  • Fax: 727-347-0893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberME62503
License Number StateFL

VIII. Authorized Official

Name: OSWALD WILLIAMS
Title or Position: PARTICIPATING MANAGER
Credential: MD
Phone: 813-774-0677