Provider Demographics
NPI:1588098495
Name:THE SHORES TREATMENT & RECOVERY SERVICES, LLC
Entity type:Organization
Organization Name:THE SHORES TREATMENT & RECOVERY SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LYLE
Authorized Official - Middle Name:RYANT
Authorized Official - Last Name:FRIED
Authorized Official - Suffix:
Authorized Official - Credentials:CAP ICADC
Authorized Official - Phone:772-800-3990
Mailing Address - Street 1:1405 SE GOLDTREE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7563
Mailing Address - Country:US
Mailing Address - Phone:772-800-3990
Mailing Address - Fax:
Practice Address - Street 1:1405 SE GOLDTREE DR
Practice Address - Street 2:SUITE A
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7563
Practice Address - Country:US
Practice Address - Phone:772-800-3990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-27
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1956AD703301101YA0400X, 324500000X
FLMH11953101YM0800X
FL4809101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty