=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811623747
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARCADIA TRAILS CENTER FOR ADDICTION RECOVERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2022
-----------------------------------------------------
Last Update Date | 07/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4851 INTEGRIS PKWY
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73034-8864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-216-2500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4851 INTEGRIS PKWY
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73034-8864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-216-2500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | JAVIER LEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-216-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------