MEDICARE: RECOVERY IN THE LIGHT 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		FL
2	2084P0800X	Psychiatry Physician	ME55819	FL

General Provider Information

NPI Number	:	1437507894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RECOVERY IN THE LIGHT LLC

Provider Business Mailing Address
First Line	:	5001 HOLLYWOOD BLVD
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-6515
Country	:	US
Telephone Number	:	954-234-2469
Fax Number	:	954-204-0464

Provider Business Practice Location Address
First Line	:	5001 HOLLYWOOD BLVD
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-6515
Country	:	US
Telephone Number	:	954-234-2469
Fax Number	:	954-204-0464

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	CATHY A PICILLO
Credential	:	OFFICE MGR
Telephone Number	:	954-234-2469

Provider Enumeration Date	:	05/26/2016
Last Update Date	:	03/06/2017

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