MEDICARE: VISION QUEST RECOVERY HOUSING INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
2	261QR0800X	Recovery Care Clinic/Center
3	324500000X	Substance Abuse Rehabilitation Facility
4	276400000X	Substance Use Disorder Rehabilitation Hospital Unit

General Provider Information

NPI Number	:	1124616479
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISION QUEST RECOVERY HOUSING INC

Provider Business Mailing Address
First Line	:	1902 13TH ST
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-6238
Country	:	US
Telephone Number	:	810-300-8536
Fax Number	:

Provider Business Practice Location Address
First Line	:	1218 LAPEER AVE # 1220
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-4352
Country	:	US
Telephone Number	:	810-300-8536
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JUSTIN KROLL
Credential	:
Telephone Number	:	810-300-8536

Provider Enumeration Date	:	01/04/2021
Last Update Date	:	01/21/2021

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