Provider Demographics
NPI:1801661251
Name:GAME TO GLORY RESTORE LLC
Entity type:Organization
Organization Name:GAME TO GLORY RESTORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:240-338-2534
Mailing Address - Street 1:4405 LARGO RD
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-7837
Mailing Address - Country:US
Mailing Address - Phone:240-338-2534
Mailing Address - Fax:
Practice Address - Street 1:2014 DUPONT AVE
Practice Address - Street 2:
Practice Address - City:SUITLAND
Practice Address - State:MD
Practice Address - Zip Code:20746-1030
Practice Address - Country:US
Practice Address - Phone:240-338-2534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility