Healthcare Provider Details

I. General information

NPI: 1174252985
Provider Name (Legal Business Name): EAGLECREST RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19965 LAKEVIEW RD
SPRINGDALE AR
72764-8892
US

IV. Provider business mailing address

PO BOX 1728
BENTONVILLE AR
72712-1728
US

V. Phone/Fax

Practice location:
  • Phone: 949-813-5161
  • Fax:
Mailing address:
  • Phone: 760-521-2653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: JUAN F HERNANDEZ
Title or Position: CEO
Credential: LMFT
Phone: 949-813-5161