Healthcare Provider Details

I. General information

NPI: 1386019727
Provider Name (Legal Business Name): A CHANGE INTO RECOVERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 12/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 E MAIN SUITE C
PUYALLUP WA
98372-3306
US

IV. Provider business mailing address

719 E MAIN SUITE C
PUYALLUP WA
98372-3306
US

V. Phone/Fax

Practice location:
  • Phone: 253-841-8165
  • Fax: 253-841-8168
Mailing address:
  • Phone: 253-841-8165
  • Fax: 253-841-8168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberCP00002706
License Number StateWA

VIII. Authorized Official

Name: MR. DAVE HARRIS
Title or Position: ADMINISTRATOR
Credential: CDP, NCAC
Phone: 253-841-8165