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General NPI Number Information
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NPI Number | 1528401072
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Entity Type | Organization
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Legal Business Name | FREEDOM RECOVERY CENTER, LLC.
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Dates
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Enumeration Date | 04/15/2013
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Last Update Date | 04/15/2013
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Provider Practice Location Address
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Address Line | 1470 W GURLEY ST
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City | PRESCOTT
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State | AZ
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Zip | 86305-2855
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Country | US
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Telephone | 928-379-0075
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Fax | 855-379-3977
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Provider Business Mailing Address
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Address Line | PO BOX 2704
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City | PRESCOTT
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State | AZ
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Zip | 86302-2704
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Country | US
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Telephone | 928-379-0075
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Fax | 855-379-3977
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Authorized Official
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Title or Position | CEO
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Name | RYAN W JESKE
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Credential |
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Telephone | 928-379-0075
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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 | BH4228
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License Number State | AZ
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