Provider Demographics
NPI:1114351509
Name:WATERS EDGE RECOVERY, LLC
Entity Type:Organization
Organization Name:WATERS EDGE RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-233-5155
Mailing Address - Street 1:117 SE SEMINOLE ST
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2122
Mailing Address - Country:US
Mailing Address - Phone:772-233-5155
Mailing Address - Fax:772-266-8383
Practice Address - Street 1:117 SE SEMINOLE ST
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2122
Practice Address - Country:US
Practice Address - Phone:772-233-5155
Practice Address - Fax:772-266-8383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-21
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility