MEDICARE: BANYAN RECOVERY INSTITUTE

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	1706AD699801	FL

General Provider Information

NPI Number	:	1598164279
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BANYAN RECOVERY INSTITUTE

Provider Business Mailing Address
First Line	:	2699 STIRLING RD STE B301
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33312-6543
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2699 STIRLING RD STE B301
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33312-6543
Country	:	US
Telephone Number	:	305-725-2514
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	MARIA COCCHIARELLA
Credential	:
Telephone Number	:	305-725-2514

Provider Enumeration Date	:	08/19/2014
Last Update Date	:	08/19/2014

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Directions to “BANYAN RECOVERY INSTITUTE ” Practice Location

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