Healthcare Provider Details

I. General information

NPI: 1750100384
Provider Name (Legal Business Name): VIA DOLOROSA RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 RODEO DR
MOREHEAD KY
40351-7470
US

IV. Provider business mailing address

55 RODEO DR
MOREHEAD KY
40351-7470
US

V. Phone/Fax

Practice location:
  • Phone: 606-784-1142
  • Fax: 606-780-0213
Mailing address:
  • Phone: 606-784-1142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. RYAN HOFFMAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 614-313-2440