MEDICARE: HOLISTIC RECOVERY CENTERS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center		FL

General Provider Information

NPI Number	:	1013366244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLISTIC RECOVERY CENTERS, LLC

Provider Business Mailing Address
First Line	:	150 NW 168TH ST
Second Line	:	SUITE 200,
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33169-6045
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 NW 168TH ST
Second Line	:	SUITE 200,
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33169-6045
Country	:	US
Telephone Number	:	954-367-7445
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	NICOLA RAJARAM
Credential	:
Telephone Number	:	954-272-6723

Provider Enumeration Date	:	06/08/2016
Last Update Date	:	06/08/2016

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