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General NPI Number Information
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NPI Number | 1609695477
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Entity Type | Organization
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Legal Business Name | REALCOVERY LLC
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Dates
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Enumeration Date | 10/08/2024
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Last Update Date | 10/08/2024
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Provider Practice Location Address
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Address Line | 2091 4TH AVE E
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City | TWIN FALLS
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State | ID
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Zip | 83301-7405
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Country | US
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Telephone | 208-731-7354
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Fax |
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Provider Business Mailing Address
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Address Line | 2067 4TH AVE E
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City | TWIN FALLS
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State | ID
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Zip | 83301-7405
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Country | US
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Telephone | 503-989-9180
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | TAYLOR WATTE
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Credential |
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Telephone | 503-989-9180
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 177F00000X
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Taxonomy Name | Lodging Provider
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License Number |
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License Number State |
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