Provider Demographics
NPI:1851964407
Name:IRECOVERY, LLC
Entity Type:Organization
Organization Name:IRECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:
Authorized Official - Last Name:CINTRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-235-7683
Mailing Address - Street 1:5030 CHAMPION BLVD STE G11-535
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-2473
Mailing Address - Country:US
Mailing Address - Phone:561-235-7683
Mailing Address - Fax:
Practice Address - Street 1:130 S INDIAN RIVER DR STE 202-6405
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4343
Practice Address - Country:US
Practice Address - Phone:772-773-6989
Practice Address - Fax:561-464-5501
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IRECOVERY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-21
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1107100606Medicaid