Healthcare Provider Details

I. General information

NPI: 1083150296
Provider Name (Legal Business Name): BRICK HOUSE RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2017
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 E PINE AVE
MERIDIAN ID
83642-5955
US

IV. Provider business mailing address

1125 E PINE AVE
MERIDIAN ID
83642-5955
US

V. Phone/Fax

Practice location:
  • Phone: 208-286-4274
  • Fax:
Mailing address:
  • Phone: 208-286-4274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateID

VIII. Authorized Official

Name: JASON DOUGLAS COOMBS
Title or Position: EXECUTIVE DIRECTOR/OWNER
Credential: MPC
Phone: 801-350-1716