MEDICARE: BLACK ROCK RECOVERY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	276400000X	Substance Use Disorder Rehabilitation Hospital Unit
2	324500000X	Substance Abuse Rehabilitation Facility
3	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1417589086
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK ROCK RECOVERY, LLC

Provider Business Mailing Address
First Line	:	25235 ORCHARD LAKE RD
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48336-1233
Country	:	US
Telephone Number	:	248-252-6192
Fax Number	:

Provider Business Practice Location Address
First Line	:	25235 ORCHARD LAKE RD
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48336-1233
Country	:	US
Telephone Number	:	248-252-6192
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	ENI V SMITH
Credential	:	MD
Telephone Number	:	248-252-6192

Provider Enumeration Date	:	02/11/2020
Last Update Date	:	02/14/2020

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