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General NPI Number Information
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NPI Number | 1104417419
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Entity Type | Organization
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Legal Business Name | BETTY LOU WALLACE RECOVERY LLC
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Dates
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Enumeration Date | 01/29/2021
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Last Update Date | 01/29/2021
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Provider Practice Location Address
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Address Line | 13645 HOLMES RD
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City | KANSAS CITY
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State | MO
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Zip | 64145-1482
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Country | US
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Telephone | 480-388-1495
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Fax |
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Provider Business Mailing Address
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Address Line | 13340 HOLMES RD
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City | KANSAS CITY
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State | MO
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Zip | 64145-1437
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Country | US
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Telephone | 816-786-7074
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | GEFFEN LIBERMAN
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Credential |
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Telephone | 480-388-1495
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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