Provider Demographics
NPI:1679210967
Name:NEW LIFE RECOVERY CENTER LLC
Entity Type:Organization
Organization Name:NEW LIFE RECOVERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VENNIETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-253-3663
Mailing Address - Street 1:302 PARK AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-3618
Mailing Address - Country:US
Mailing Address - Phone:240-253-3663
Mailing Address - Fax:443-836-9157
Practice Address - Street 1:5016 QUEENSBERRY AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5119
Practice Address - Country:US
Practice Address - Phone:240-253-3663
Practice Address - Fax:443-836-9157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-17
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility