MEDICARE: UNDER ANGEL'S WINGS RECOVERY CENTER, 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	261Q00000X	Clinic/Center
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1861100646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNDER ANGEL'S WINGS RECOVERY CENTER, LLC

Provider Business Mailing Address
First Line	:	1588 E 58TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-4102
Country	:	US
Telephone Number	:	917-620-0105
Fax Number	:

Provider Business Practice Location Address
First Line	:	5411 2ND AVE FL 1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-2664
Country	:	US
Telephone Number	:	718-374-5484
Fax Number	:

Authorized Official
Title or Position	:	BILLING COORDINATOR
Name	:	MR. VLADIMIR DELBRUNE
Credential	:	MBA
Telephone Number	:	917-362-4332

Provider Enumeration Date	:	11/09/2022
Last Update Date	:	12/07/2022

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