Provider Demographics
NPI:1932794120
Name:MID-ATLANTIC RECOVERY CENTER SHENANDOAH LLC
Entity Type:Organization
Organization Name:MID-ATLANTIC RECOVERY CENTER SHENANDOAH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:GEREN
Authorized Official - Last Name:BROADNAX
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MTS
Authorized Official - Phone:706-294-0807
Mailing Address - Street 1:15 PRATTS RUN STE AO1
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980-6606
Mailing Address - Country:US
Mailing Address - Phone:540-221-4912
Mailing Address - Fax:
Practice Address - Street 1:15 PRATTS RUN STE AO1
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980-6606
Practice Address - Country:US
Practice Address - Phone:540-221-4912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health