Provider Demographics
NPI:1740696442
Name:OPIATE RECOVERY NETWORK, LLC
Entity type:Organization
Organization Name:OPIATE RECOVERY NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTICIPATING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OSWALD
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-774-0677
Mailing Address - Street 1:502 PASADENA AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-2126
Mailing Address - Country:US
Mailing Address - Phone:727-381-9500
Mailing Address - Fax:727-347-0893
Practice Address - Street 1:6101 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713
Practice Address - Country:US
Practice Address - Phone:727-527-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62503261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1063698744Medicare UPIN