Provider Demographics
NPI:1053681205
Name:BEADED STAR RECOVERY,LLC
Entity Type:Organization
Organization Name:BEADED STAR RECOVERY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:K
Authorized Official - Last Name:DAHL
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD/N, MBA, CEDRD
Authorized Official - Phone:904-241-3113
Mailing Address - Street 1:2380 3RD ST S
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-4023
Mailing Address - Country:US
Mailing Address - Phone:904-241-3113
Mailing Address - Fax:904-513-9268
Practice Address - Street 1:2380 3RD ST S
Practice Address - Street 2:SUITE 1
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4023
Practice Address - Country:US
Practice Address - Phone:904-241-3113
Practice Address - Fax:904-513-9268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-05
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8334101YM0800X
FLND546133V00000X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty