MEDICARE: HOPE & GRACE RECOVERY CENTER, 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

General Provider Information

NPI Number	:	1295107381
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOPE & GRACE RECOVERY CENTER, LLC

Provider Business Mailing Address
First Line	:	3401 POWERLINE RD
Second Line	:	SUITE 200
City	:	OAKLAND PARK
State	:	FL
Zip	:	33309
Country	:	US
Telephone Number	:	954-616-8988
Fax Number	:	954-616-5951

Provider Business Practice Location Address
First Line	:	3411 NW 9TH AVE # 703704
Second Line	:
City	:	OAKLAND PARK
State	:	FL
Zip	:	33309-5946
Country	:	US
Telephone Number	:	617-448-8721
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	MR. KENNETH FITZEMEYER
Credential	:
Telephone Number	:	754-216-3338

Provider Enumeration Date	:	10/28/2015
Last Update Date	:	01/08/2019

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