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General NPI Number Information
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NPI Number | 1831748573
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Entity Type | Organization
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Legal Business Name | RECOVERUSCENTERS-CARBONDALE LLC
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Dates
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Enumeration Date | 09/05/2019
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Last Update Date | 09/05/2019
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Provider Practice Location Address
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Address Line | 2250 REED STATION PKWY STE 204
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City | CARBONDALE
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State | IL
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Zip | 62901-8104
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Country | US
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Telephone | 618-519-9445
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Fax |
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Provider Business Mailing Address
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Address Line | 2250 REED STATION PKWY STE 204
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City | CARBONDALE
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State | IL
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Zip | 62901-8104
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MILTON THEODORE MORTER III
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Credential | DC
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Telephone | 479-619-9320
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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