Healthcare Provider Details

I. General information

NPI: 1609695477
Provider Name (Legal Business Name): REALCOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2091 4TH AVE E
TWIN FALLS ID
83301-7405
US

IV. Provider business mailing address

2067 4TH AVE E
TWIN FALLS ID
83301-7405
US

V. Phone/Fax

Practice location:
  • Phone: 208-731-7354
  • Fax:
Mailing address:
  • Phone: 503-989-9180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: TAYLOR WATTE
Title or Position: ADMINISTRATOR
Credential:
Phone: 503-989-9180