Healthcare Provider Details

I. General information

NPI: 1104106418
Provider Name (Legal Business Name): CARLETON RECOVERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2011
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

637 W HILLSIDE AVE
PRESCOTT AZ
86301-1915
US

IV. Provider business mailing address

505 W. WHIPPLE ST.
PRESCOTT AZ
86301
US

V. Phone/Fax

Practice location:
  • Phone: 928-708-9615
  • Fax: 928-708-9620
Mailing address:
  • Phone: 928-778-4600
  • Fax: 928-778-2221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberBH-3908
License Number StateAZ

VIII. Authorized Official

Name: MR. FRED SCHAFFNER
Title or Position: CHEIF FINANCIAL OFFICER
Credential:
Phone: 928-778-4600