Provider Demographics
NPI:1326800798
Name:RECOVERY 180 VIRGINIA LLC
Entity Type:Organization
Organization Name:RECOVERY 180 VIRGINIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-839-6928
Mailing Address - Street 1:1100 BUSINESS PKWY S STE 1
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-3048
Mailing Address - Country:US
Mailing Address - Phone:443-839-6928
Mailing Address - Fax:
Practice Address - Street 1:6791 JAMES MADISON HWY
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20187-9534
Practice Address - Country:US
Practice Address - Phone:443-289-8606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RECOVERY 180 VIRGINIA LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8228-02-033OtherFACILITY LICENSE
VA8228-02-035OtherFACILITY LICENSE