MEDICARE: ASIC RECOVERY SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center
2	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1093382517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASIC RECOVERY SERVICES LLC

Provider Business Mailing Address
First Line	:	3256 LACKLAND RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5307
Country	:	US
Telephone Number	:	832-681-9643
Fax Number	:	817-616-0758

Provider Business Practice Location Address
First Line	:	3256 LACKLAND RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5307
Country	:	US
Telephone Number	:	817-616-0504
Fax Number	:	817-616-0758

Authorized Official
Title or Position	:	OWNER
Name	:	THEA PHAM
Credential	:
Telephone Number	:	832-681-9643

Provider Enumeration Date	:	06/04/2021
Last Update Date	:	06/17/2026

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Directions to “ASIC RECOVERY SERVICES LLC ” Practice Location

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