Provider Demographics
NPI:1265856017
Name:THE RECOVERY VILLAGE
Entity type:Organization
Organization Name:THE RECOVERY VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:754-300-3120
Mailing Address - Street 1:100 SE THIRD AVE
Mailing Address - Street 2:SUITE 1102
Mailing Address - City:FT. LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33394
Mailing Address - Country:US
Mailing Address - Phone:754-300-3120
Mailing Address - Fax:
Practice Address - Street 1:633 UMATILLA BLVD.
Practice Address - Street 2:THE RECOVERY VILLAGE
Practice Address - City:UMATILLA
Practice Address - State:FL
Practice Address - Zip Code:32784
Practice Address - Country:US
Practice Address - Phone:352-669-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-14
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility