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NPI Code Detail

MEDICARE: RECOVERY VILLAGE AT PALMER LAKE, LLC

MEDICARE: RECOVERY VILLAGE AT PALMER LAKE, 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
1324500000XSubstance Abuse Rehabilitation Facility

General Provider Information

NPI Number : 1356738132
Entity Type Code : Organization
Provider Name (Legal Business Name) : RECOVERY VILLAGE AT PALMER LAKE, LLC
Provider Business Mailing Address
First Line : 100 SE THIRD AVE, SUITE 1800
Second Line :
City : FORT LAUDERDALE
State : FL
Zip : 33394
Country : US
Telephone Number : 754-300-3120
Fax Number : 888-919-4431
Provider Business Practice Location Address
First Line : 443 HIGHWAY 105
Second Line :
City : PALMER LAKE
State : CO
Zip : 80133-9003
Country : US
Telephone Number : 719-481-1800
Fax Number :
Authorized Official
Title or Position : LICENSING & CONTRACTING DIRECTOR
Name : BELINA SURUJON
Credential :
Telephone Number : 754-300-3120
Provider Enumeration Date : 04/20/2015
Last Update Date : 06/17/2019

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1336097120 — RECOVERY VILLAGE AT PALMER LAKE, LLC
Practice Location Address:
443 HIGHWAY 105
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80133-9003
Practice Phone: 305-785-5520
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1760998892 — CYNTHIA WHITE MS, LAC
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1003400227 — MS. CAROLINE HONORA STORK LSW, CCTP, CADC
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Directions to “RECOVERY VILLAGE AT PALMER LAKE, LLC ” Practice Location

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