Healthcare Provider Details

I. General information

NPI: 1629339437
Provider Name (Legal Business Name): RE-CREATION RETREAT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 11/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 SOUTH MAIN
FREDONIA AZ
86022
US

IV. Provider business mailing address

380 W LOS BARANCOS LN P.O. BOX 61
KANAB UT
84741-3311
US

V. Phone/Fax

Practice location:
  • Phone: 435-691-0856
  • Fax:
Mailing address:
  • Phone: 435-691-0856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberBH-3895
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberBH-3895
License Number StateAZ

VIII. Authorized Official

Name: MR. RANDY K SODERQUIST
Title or Position: OWNER AND CLINICAL DIRECTOR
Credential: LCSW
Phone: 435-691-0856