Healthcare Provider Details

I. General information

NPI: 1669090668
Provider Name (Legal Business Name): ALTRUISTIC RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1052 SW 4TH AVE STE 2
ONTARIO OR
97914-2100
US

IV. Provider business mailing address

PO BOX 658
ONTARIO OR
97914-0658
US

V. Phone/Fax

Practice location:
  • Phone: 208-550-7920
  • Fax:
Mailing address:
  • Phone: 208-550-7920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. NICHOLE RAE LOW
Title or Position: MEMBER
Credential: CADC I
Phone: 208-550-7920