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General NPI Number Information
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NPI Number | 1306484860
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Entity Type | Organization
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Legal Business Name | EAGLECREST RECOVERY LLC
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Dates
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Enumeration Date | 12/16/2019
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Last Update Date | 05/19/2020
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Provider Practice Location Address
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Address Line | 1106 SW 2ND ST
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City | BENTONVILLE
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State | AR
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Zip | 72712-5026
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Country | US
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Telephone | 479-367-2691
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Fax | 479-367-2899
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Provider Business Mailing Address
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Address Line | 1101 SW COVENTRY BLVD
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City | BENTONVILLE
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State | AR
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Zip | 72712-4325
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Country | US
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Telephone | 479-367-2691
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Fax | 479-367-2899
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Authorized Official
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Title or Position | CEO
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Name | JUAN F HERNANDEZ
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Credential |
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Telephone | 949-813-5161
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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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