Healthcare Provider Details

I. General information

NPI: 1073021853
Provider Name (Legal Business Name): 11100 BILLINGSLEY ROAD OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 BILLINGSLEY RD
WALDORF MD
20602-3400
US

IV. Provider business mailing address

2701 RENAISSANCE BLVD FL 4
KING OF PRUSSIA PA
19406-2781
US

V. Phone/Fax

Practice location:
  • Phone: 240-754-6100
  • Fax:
Mailing address:
  • Phone: 610-994-2968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: SERGE CRUZ
Title or Position: CORP DIR PATIENT ACCOUNTS
Credential:
Phone: 610-427-9434