Healthcare Provider Details

I. General information

NPI: 1063067049
Provider Name (Legal Business Name): FAMILY RECOVERY PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 N GAY ST
BALTIMORE MD
21202-4822
US

IV. Provider business mailing address

239 N GAY ST
BALTIMORE MD
21202-4822
US

V. Phone/Fax

Practice location:
  • Phone: 410-605-0492
  • Fax:
Mailing address:
  • Phone: 410-605-0492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. JOCELYN GAINERS
Title or Position: CEO/DIRECTOR
Credential:
Phone: 410-605-0492