MEDICARE: REBUILD ELEVATE ACHEIVE AND LIVE (REAL) 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

General Provider Information

NPI Number	:	1447083829
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REBUILD ELEVATE ACHEIVE AND LIVE (REAL) LLC

Provider Business Mailing Address
First Line	:	7034 LIBERTY RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-5801
Country	:	US
Telephone Number	:	240-749-5433
Fax Number	:

Provider Business Practice Location Address
First Line	:	7034 LIBERTY RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-5801
Country	:	US
Telephone Number	:	240-749-5433
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRIAN GRIMM
Credential	:
Telephone Number	:	443-453-3608

Provider Enumeration Date	:	08/21/2024
Last Update Date	:	08/21/2024

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