Healthcare Provider Details

I. General information

NPI: 1871949388
Provider Name (Legal Business Name): THE RECOVERY VILLAGE MARYLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13400 EDGEMEADE ROAD
UPPER MARLBORO MD
20772
US

IV. Provider business mailing address

100 SE 3RD AVE SUITE 1800
FT LAUDERDALE FL
33394-0002
US

V. Phone/Fax

Practice location:
  • Phone: 754-300-3120
  • Fax: 888-919-4431
Mailing address:
  • Phone: 754-300-3120
  • Fax: 888-919-4431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number16-023
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: BELINA SURUJON
Title or Position: LICENSING & CONTRACTING DIRECTOR
Credential:
Phone: 754-300-3120