Provider Demographics
NPI:1871949388
Name:THE RECOVERY VILLAGE MARYLAND, LLC
Entity type:Organization
Organization Name:THE RECOVERY VILLAGE MARYLAND, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSING & CONTRACTING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BELINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SURUJON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:754-300-3120
Mailing Address - Street 1:100 SE 3RD AVE
Mailing Address - Street 2:SUITE 1800
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33394-0002
Mailing Address - Country:US
Mailing Address - Phone:754-300-3120
Mailing Address - Fax:888-919-4431
Practice Address - Street 1:13400 EDGEMEADE ROAD
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772
Practice Address - Country:US
Practice Address - Phone:754-300-3120
Practice Address - Fax:888-919-4431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-13
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16-023323P00000X
324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility