=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518478940
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREG'S RECOVERY GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2017
-----------------------------------------------------
Last Update Date | 12/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2045 N UNIVERSITY DR
-----------------------------------------------------
City | SUNRISE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33322-3936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-947-8732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2045 N UNIVERSITY DR
-----------------------------------------------------
City | SUNRISE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33322-3936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JESSICA A WATKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-213-4103
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------