Provider Demographics
NPI:1760610109
Name:FRONTLINE RECOVERY, LLC
Entity Type:Organization
Organization Name:FRONTLINE RECOVERY, LLC
Other - Org Name:JOLIMAR RECOVERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYBORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-276-9556
Mailing Address - Street 1:PO BOX 1176
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:MS
Mailing Address - Zip Code:39666-1176
Mailing Address - Country:US
Mailing Address - Phone:601-276-9556
Mailing Address - Fax:601-276-9578
Practice Address - Street 1:1038 RIVER RIDGE RD
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:MS
Practice Address - Zip Code:39666-9715
Practice Address - Country:US
Practice Address - Phone:601-276-9556
Practice Address - Fax:601-276-9578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSFS36BAEAPR/TR-OP-O1324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility