MEDICARE: THE LODGE RECOVERY SERVICES, 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	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1629317797
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE LODGE RECOVERY SERVICES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 7004
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33482-7004
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2542 BESSIE ST
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33444-2106
Country	:	US
Telephone Number	:	561-945-7560
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JAMES TICHY
Credential	:
Telephone Number	:	561-945-7560

Provider Enumeration Date	:	02/08/2013
Last Update Date	:	02/08/2013

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