Provider Demographics
NPI:1144839283
Name:ST JOHN'S RECOVERY PLACE LLC
Entity type:Organization
Organization Name:ST JOHN'S RECOVERY PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-945-2984
Mailing Address - Street 1:ST JOHNS RECOVERY PLACE LLC
Mailing Address - Street 2:1125 N SUMMIT STREET
Mailing Address - City:CRESCENT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32112
Mailing Address - Country:US
Mailing Address - Phone:954-945-2984
Mailing Address - Fax:
Practice Address - Street 1:ST JOHNS RECOVERY PLACE LLC
Practice Address - Street 2:109 SILVER PALM AVENUE
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:954-945-2984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-24
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder