Provider Demographics
NPI:1356738132
Name:RECOVERY VILLAGE AT PALMER LAKE, LLC
Entity type:Organization
Organization Name:RECOVERY VILLAGE AT PALMER LAKE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSING & CONTRACTING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BELINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SURUJON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:754-300-3120
Mailing Address - Street 1:100 SE THIRD AVE, SUITE 1800
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33394
Mailing Address - Country:US
Mailing Address - Phone:754-300-3120
Mailing Address - Fax:888-919-4431
Practice Address - Street 1:443 HIGHWAY 105
Practice Address - Street 2:
Practice Address - City:PALMER LAKE
Practice Address - State:CO
Practice Address - Zip Code:80133-9003
Practice Address - Country:US
Practice Address - Phone:719-481-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-20
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility