Provider Demographics
NPI:1194308692
Name:OUTREACH RECOVERY II
Entity type:Organization
Organization Name:OUTREACH RECOVERY II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ISIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:COLES
Authorized Official - Suffix:
Authorized Official - Credentials:ATC
Authorized Official - Phone:561-502-3978
Mailing Address - Street 1:4201 NORTHVIEW DR STE 104
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-2655
Mailing Address - Country:US
Mailing Address - Phone:561-502-3978
Mailing Address - Fax:410-705-5024
Practice Address - Street 1:22330 CHANCELLORS RUN RD UNIT A
Practice Address - Street 2:
Practice Address - City:GREAT MILLS
Practice Address - State:MD
Practice Address - Zip Code:20634-2424
Practice Address - Country:US
Practice Address - Phone:410-800-4466
Practice Address - Fax:410-705-5024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
20634OtherZIP CODE