Healthcare Provider Details

I. General information

NPI: 1578828083
Provider Name (Legal Business Name): RECOVERY ROAD CHARITABLE NON PROFIT ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 11/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

961 ALPINE AVE NW
GRAND RAPIDS MI
49504-4451
US

IV. Provider business mailing address

2666 SEYMOUR DR
SHELBYVILLE MI
49344-9523
US

V. Phone/Fax

Practice location:
  • Phone: 616-915-0594
  • Fax:
Mailing address:
  • Phone: 269-792-4173
  • Fax: 269-792-4173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. PRESTON R SMITH
Title or Position: TREASURER
Credential:
Phone: 269-792-4173