=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699238279
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARIZONA RECOVERY CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2019
-----------------------------------------------------
Last Update Date | 01/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 84 ACOMA BLVD N STE 104
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-6096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-351-3030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 84 ACOMA BLVD N STE 104
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-6096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-733-5101
-----------------------------------------------------
Fax | 928-235-5588
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITONER/OWNER
-----------------------------------------------------
Name | EMILY VONA
-----------------------------------------------------
Credential | FNP-C
-----------------------------------------------------
Telephone | 289-733-5101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------