MEDICARE: EDGE RECOVERY TREATMENT, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251S00000X	Community/Behavioral Health Agency
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
3	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1063075000
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDGE RECOVERY TREATMENT, LLC

Provider Business Mailing Address
First Line	:	3000 NW 101ST LN
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33065-3930
Country	:	US
Telephone Number	:	954-272-4073
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 NW 101ST LN
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33065-3930
Country	:	US
Telephone Number	:	954-272-4073
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KIM CHIDDO
Credential	:
Telephone Number	:	954-272-4073

Provider Enumeration Date	:	04/16/2019
Last Update Date	:	11/17/2019

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