Provider Demographics
NPI:1730956293
Name:RECOVER UNDERCOVER LLC
Entity type:Organization
Organization Name:RECOVER UNDERCOVER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:631-546-8849
Mailing Address - Street 1:39 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-2122
Mailing Address - Country:US
Mailing Address - Phone:631-546-8849
Mailing Address - Fax:
Practice Address - Street 1:39 WHEELER RD
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-2122
Practice Address - Country:US
Practice Address - Phone:631-546-8849
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-05
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No177F00000XOther Service ProvidersLodgingGroup - Single Specialty