Healthcare Provider Details

I. General information

NPI: 1639043011
Provider Name (Legal Business Name): 11100 BILLINGSLEY ROAD OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2025
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 BILLINGSLEY RD
WALDORF MD
20602-3400
US

IV. Provider business mailing address

2201 RENAISSANCE BLVD FL 3
KING OF PRUSSIA PA
19406-2709
US

V. Phone/Fax

Practice location:
  • Phone: 240-754-6137
  • Fax:
Mailing address:
  • Phone: 484-971-6409
  • 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: RAY MOLINA
Title or Position: DIR PAYER RELATIONS
Credential:
Phone: 954-716-2790