MEDICARE: ROCKIN RECOVERY LIFE SKILLS, 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	324500000X	Substance Abuse Rehabilitation Facility	1550AD185301	FL
2	261QR0800X	Recovery Care Clinic/Center

General Provider Information

NPI Number	:	1225494529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROCKIN RECOVERY LIFE SKILLS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 6542
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33482-6542
Country	:	US
Telephone Number	:	561-255-3573
Fax Number	:	561-808-7394

Provider Business Practice Location Address
First Line	:	265 NE 5TH AVE
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33483-5530
Country	:	US
Telephone Number	:	561-255-3573
Fax Number	:	561-808-7394

Authorized Official
Title or Position	:	SENIOR CREDENTIALING SPECIALIST
Name	:	KELI KORNMILLER
Credential	:
Telephone Number	:	561-672-8345

Provider Enumeration Date	:	01/04/2016
Last Update Date	:	01/29/2016

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