=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306475751
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARAMOUNT RECOVERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2020
-----------------------------------------------------
Last Update Date | 12/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 637 W HILLSIDE AVE
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86301-1909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-370-3523
-----------------------------------------------------
Fax | 866-868-3056
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 637 W HILLSIDE AVE
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86301-1909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-222-1485
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | KEVIN ROSS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-903-7445
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------