Provider Demographics
NPI:1053076364
Name:PROGRESSIVE RECOVERY LLC
Entity Type:Organization
Organization Name:PROGRESSIVE RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENCY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LATISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-767-9817
Mailing Address - Street 1:5309 MONROE RD STE 112
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-7829
Mailing Address - Country:US
Mailing Address - Phone:917-767-9817
Mailing Address - Fax:
Practice Address - Street 1:8310 CAROB TREE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-7142
Practice Address - Country:US
Practice Address - Phone:917-767-9817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-02
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC00000Medicaid