Provider Demographics
NPI:1184223406
Name:ST JOHN'S RECOVERY PLACE LLC
Entity Type:Organization
Organization Name:ST JOHN'S RECOVERY PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-945-2984
Mailing Address - Street 1:1125 N SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32112-1721
Mailing Address - Country:US
Mailing Address - Phone:954-945-2984
Mailing Address - Fax:904-990-1201
Practice Address - Street 1:1045 WILLIAMSBURG RD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-1449
Practice Address - Country:US
Practice Address - Phone:954-945-2984
Practice Address - Fax:904-990-1201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder