=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356050066
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMPOWER RECOVERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2022
-----------------------------------------------------
Last Update Date | 11/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4857 W VAN BUREN ST STE 250
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85043-3850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-284-7422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4857 W VAN BUREN ST STE 250
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85043-3850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-405-3442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SAMIIRA HUSSEIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 858-405-3442
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------