=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942780960
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RECOVERING HOPE TREATMENT CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2018
-----------------------------------------------------
Last Update Date | 08/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2031 ROWLAND RD
-----------------------------------------------------
City | MORA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55051-7119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-364-1315
-----------------------------------------------------
Fax | 320-364-1320
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2031 ROWLAND RD
-----------------------------------------------------
City | MORA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55051-7119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-364-1315
-----------------------------------------------------
Fax | 320-364-1320
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | JENNA KAREN LUDOWESE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 320-364-1314
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------