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General NPI Number Information
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NPI Number | 1639043011
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Entity Type | Organization
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Legal Business Name | 11100 BILLINGSLEY ROAD OPCO LLC
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Dates
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Enumeration Date | 09/30/2025
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Last Update Date | 09/30/2025
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Provider Practice Location Address
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Address Line | 11100 BILLINGSLEY RD
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City | WALDORF
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State | MD
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Zip | 20602-3400
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Country | US
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Telephone | 240-754-6137
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Fax |
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Provider Business Mailing Address
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Address Line | 2201 RENAISSANCE BLVD FL 3
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City | KING OF PRUSSIA
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State | PA
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Zip | 19406-2709
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Country | US
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Telephone | 484-971-6409
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Fax |
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Authorized Official
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Title or Position | DIR PAYER RELATIONS
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Name | RAY MOLINA
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Credential |
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Telephone | 954-716-2790
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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