MEDICARE: FALLING LEAVES RECOVERY 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	1302	FL
2	324500000X	Substance Abuse Rehabilitation Facility	1302	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10D2122335	OTHER	FL	CLIA
2	YGC	OTHER	FL	BCBS
3	Z4YG9	OTHER	FL	BCBS GROUP ID

General Provider Information

NPI Number	:	1346698693
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FALLING LEAVES RECOVERY LLC

Provider Business Mailing Address
First Line	:	5079 N DIXIE HWY
Second Line	:	198
City	:	OAKLAND PARK
State	:	FL
Zip	:	33334-4000
Country	:	US
Telephone Number	:	786-332-2218
Fax Number	:	954-357-3624

Provider Business Practice Location Address
First Line	:	15485 EAGLE NEST LN
Second Line	:	SUITE 210 & 230
City	:	MIAMI LAKES
State	:	FL
Zip	:	33014-2247
Country	:	US
Telephone Number	:	786-332-2218
Fax Number	:	786-332-4994

Authorized Official
Title or Position	:	CFO
Name	:	MARK SHEPPARD
Credential	:
Telephone Number	:	832-289-3350

Provider Enumeration Date	:	05/26/2016
Last Update Date	:	07/21/2022

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