=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225894017
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RECOVERY SPACE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2024
-----------------------------------------------------
Last Update Date | 02/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1535 N CARLISLE ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19121-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-766-3494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1535 N CARLISLE ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19121-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-766-3494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | YOLA VITAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 908-764-4513
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------