=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629651971
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNITED RECOVERY CENTERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2021
-----------------------------------------------------
Last Update Date | 05/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17781 HORNBEAN DR
-----------------------------------------------------
City | WILDWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63005-4229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-908-1253
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17781 HORNBEAN DR
-----------------------------------------------------
City | WILDWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63005-4229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-908-1253
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SARFARAZ ABDEALI JASDANWALA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 312-953-5636
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------