MEDICARE: CENTER CITY RECOVERY, 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	807440	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	807440	OTHER	PA	CERTIFICATE OF LICENSURE

General Provider Information

NPI Number	:	1790213122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTER CITY RECOVERY, LLC

Provider Business Mailing Address
First Line	:	1880 JFK BLVD STE 1110
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-7422
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1880 JFK BLVD STE 1110
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-7422
Country	:	US
Telephone Number	:	215-398-5304
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	VALERIE DORELIEN
Credential	:
Telephone Number	:	215-398-5304

Provider Enumeration Date	:	05/30/2017
Last Update Date	:	06/11/2019

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Directions to “CENTER CITY RECOVERY, LLC ” Practice Location

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