Healthcare Provider Details

I. General information

NPI: 1184011397
Provider Name (Legal Business Name): ADDICTION RECOVERY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2015
Last Update Date: 05/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 S MAIN ST SUITE 512
SALT LAKE CITY UT
84111-1916
US

IV. Provider business mailing address

175 S MAIN ST 512
SALT LAKE CITY UT
84111-1916
US

V. Phone/Fax

Practice location:
  • Phone: 801-830-2915
  • Fax:
Mailing address:
  • Phone: 801-830-2915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number6854100-6006
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number6854100-6004
License Number StateUT

VIII. Authorized Official

Name: NICOLE C NELSON
Title or Position: PRESIDENT
Credential:
Phone: 801-830-2915