Provider Demographics
NPI:1073063202
Name:ORCHARD MOUNTAIN RECOVERY LLC
Entity Type:Organization
Organization Name:ORCHARD MOUNTAIN RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:LUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:NCAC II, CSAC, SAP
Authorized Official - Phone:434-282-2294
Mailing Address - Street 1:355 RIO RD W STE 203
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-1361
Mailing Address - Country:US
Mailing Address - Phone:434-282-2294
Mailing Address - Fax:434-282-2644
Practice Address - Street 1:355 RIO RD W STE 203
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-1361
Practice Address - Country:US
Practice Address - Phone:434-282-2294
Practice Address - Fax:434-282-2644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2877-02-001261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder