MEDICARE: NEW WATERS RECOVERY NORTH CAROLINA 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

General Provider Information

NPI Number	:	1215887625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW WATERS RECOVERY NORTH CAROLINA LLC

Provider Business Mailing Address
First Line	:	3810 BLAND RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-6239
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3810 BLAND RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-6239
Country	:	US
Telephone Number	:	561-632-0120
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JUSTIN MCLENDON
Credential	:	LCMHC, LCAS, CCS
Telephone Number	:	561-632-0120

Provider Enumeration Date	:	02/03/2026
Last Update Date	:	02/03/2026

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