=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972969277
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELEVATION RECOVERY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2016
-----------------------------------------------------
Last Update Date | 01/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1509 N MILITARY TRL STE 100
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33409-4765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-683-9270
-----------------------------------------------------
Fax | 561-683-9279
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1509 N MILITARY TRL STE 100
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33409-4765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-683-9270
-----------------------------------------------------
Fax | 561-683-9279
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | KELI KORNMILLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-672-8345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 1550AD404201
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0800X
-----------------------------------------------------
Taxonomy Name | Recovery Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------