=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013444181
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREEDOM RECOVERY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2017
-----------------------------------------------------
Last Update Date | 05/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 715 E YELM AVE STE 6
-----------------------------------------------------
City | YELM
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98597-8714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-960-8595
-----------------------------------------------------
Fax | 253-960-8594
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 715 E YELM AVE STE 6
-----------------------------------------------------
City | YELM
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98597-8714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-961-0116
-----------------------------------------------------
Fax | 253-960-8594
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. ROBERT WAYNE LONG
-----------------------------------------------------
Credential | CDP
-----------------------------------------------------
Telephone | 360-960-8595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 145800
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------