Healthcare Provider Details

I. General information

NPI: 1083339782
Provider Name (Legal Business Name): NEW LIFE RECOVERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 SAINT PAUL ST
BALTIMORE MD
21202-1704
US

IV. Provider business mailing address

302 PARK AVE STE 1
BALTIMORE MD
21201-3618
US

V. Phone/Fax

Practice location:
  • Phone: 240-253-3663
  • Fax:
Mailing address:
  • Phone: 240-253-3663
  • Fax: 443-836-9157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. VENNEITH MCCORMICK
Title or Position: DIRECTOR
Credential:
Phone: 240-253-3663