MEDICARE: LEESBURG TREATMENT 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
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1851098743
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEESBURG TREATMENT SERVICES, LLC

Provider Business Mailing Address
First Line	:	1317 ROUTE 73 STE 200
Second Line	:
City	:	MOUNT LAUREL
State	:	NJ
Zip	:	08054-2202
Country	:	US
Telephone Number	:	856-439-6111
Fax Number	:

Provider Business Practice Location Address
First Line	:	7622 COMANCHE DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-1144
Country	:	US
Telephone Number	:	804-533-1330
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR OF CONTRACT MGMT
Name	:	ROBYN TANIS
Credential	:
Telephone Number	:	856-533-8762

Provider Enumeration Date	:	02/10/2023
Last Update Date	:	02/10/2023

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