Provider Demographics
NPI:1225894017
Name:RECOVERY SPACE
Entity Type:Organization
Organization Name:RECOVERY SPACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:VITAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-764-4513
Mailing Address - Street 1:1535 N CARLISLE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-4314
Mailing Address - Country:US
Mailing Address - Phone:855-766-3494
Mailing Address - Fax:
Practice Address - Street 1:1535 N CARLISLE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-4314
Practice Address - Country:US
Practice Address - Phone:855-766-3494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty