Healthcare Provider Details

I. General information

NPI: 1003462623
Provider Name (Legal Business Name): REALIZE RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2019
Last Update Date: 08/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3775 IRIS AVE STE 6
BOULDER CO
80301-2043
US

IV. Provider business mailing address

3775 IRIS AVE STE 6
BOULDER CO
80301-2043
US

V. Phone/Fax

Practice location:
  • Phone: 512-644-8598
  • Fax:
Mailing address:
  • Phone: 512-644-8598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: QUDDUS FUJITA MAUS
Title or Position: OWNER
Credential: MA, LPC
Phone: 512-644-8598