=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104464544
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRESCOTT RECOVERY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2019
-----------------------------------------------------
Last Update Date | 12/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 805 WHITE SPAR RD
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86303-4636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-899-8105
-----------------------------------------------------
Fax | 866-697-2326
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 805 WHITE SPAR RD
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86303-4636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF FINANCE
-----------------------------------------------------
Name | DEBRA KIMBRO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-633-3384
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------