Healthcare Provider Details

I. General information

NPI: 1699395368
Provider Name (Legal Business Name): ROADRUNNER RECOVERY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 13TH ST SW APT A
ALBUQUERQUE NM
87102-2873
US

IV. Provider business mailing address

505 13TH ST SW APT A
ALBUQUERQUE NM
87102-2873
US

V. Phone/Fax

Practice location:
  • Phone: 505-221-4009
  • Fax:
Mailing address:
  • Phone: 505-221-4009
  • Fax:

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: JAMES COOPER
Title or Position: OWNER
Credential:
Phone: 505-221-4009