Healthcare Provider Details

I. General information

NPI: 1427421098
Provider Name (Legal Business Name): RECOVIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

337 E CORONADO RD STE 201
PHOENIX AZ
85004-1583
US

IV. Provider business mailing address

PO BOX 20216
PHOENIX AZ
85036-0216
US

V. Phone/Fax

Practice location:
  • Phone: 480-219-7178
  • Fax: 480-219-7138
Mailing address:
  • Phone: 480-219-7178
  • Fax: 480-219-7138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. CINDY PROFFITT
Title or Position: BILLING DIRECTOR
Credential: CCS, CPB, EMT-P
Phone: 480-219-7178