MEDICARE: ACTIVE RECOVERY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1104460666
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE RECOVERY, LLC

Provider Business Mailing Address
First Line	:	25 S MAIN ST # 212
Second Line	:
City	:	CENTERVILLE
State	:	UT
Zip	:	84014-1840
Country	:	US
Telephone Number	:	801-663-6656
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 S MAIN ST # 212
Second Line	:
City	:	CENTERVILLE
State	:	UT
Zip	:	84014-1840
Country	:	US
Telephone Number	:	801-663-6656
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	LANCE HORI
Credential	:	CPA
Telephone Number	:	801-628-4944

Provider Enumeration Date	:	10/28/2019
Last Update Date	:	10/28/2019

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