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General NPI Number Information
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NPI Number | 1073063202
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Entity Type | Organization
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Legal Business Name | ORCHARD MOUNTAIN RECOVERY LLC
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Dates
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Enumeration Date | 10/12/2016
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Last Update Date | 10/12/2016
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Provider Practice Location Address
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Address Line | 355 RIO RD W STE 203
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22901-1361
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Country | US
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Telephone | 434-282-2294
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Fax | 434-282-2644
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Provider Business Mailing Address
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Address Line | 355 RIO RD W STE 203
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22901-1361
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Country | US
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Telephone | 434-282-2294
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Fax | 434-282-2644
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Authorized Official
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Title or Position | COO
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Name | MR. RANDALL WILLIAM LUSTER
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Credential | NCAC II, CSAC, SAP
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Telephone | 434-282-2294
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 2877-02-001
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License Number State | VA
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