Provider Demographics
NPI:1700313830
Name:GRAPEVINE RECOVERY ASSOCIATES LLC
Entity Type:Organization
Organization Name:GRAPEVINE RECOVERY ASSOCIATES LLC
Other - Org Name:GRAPEVINE RECOVERY ASSOCIATES LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:B
Authorized Official - Last Name:SATROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-708-9671
Mailing Address - Street 1:2342 MONARCH TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-2626
Mailing Address - Country:US
Mailing Address - Phone:301-708-9671
Mailing Address - Fax:
Practice Address - Street 1:7580 BEACH DR
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-2508
Practice Address - Country:US
Practice Address - Phone:301-708-9671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-19
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder