Provider Demographics
NPI:1578012589
Name:SQUARE ONE RECOVERY, LLC
Entity Type:Organization
Organization Name:SQUARE ONE RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ONBOARDING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KELI
Authorized Official - Middle Name:
Authorized Official - Last Name:KORNMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-672-8345
Mailing Address - Street 1:11576 PIERSON RD
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-8767
Mailing Address - Country:US
Mailing Address - Phone:561-512-9273
Mailing Address - Fax:561-345-6561
Practice Address - Street 1:11576 PIERSON RD
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-8767
Practice Address - Country:US
Practice Address - Phone:561-512-9273
Practice Address - Fax:561-345-6561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-03
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5081347114901261QR0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care