MEDICARE: VIDA 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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1235911611
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIDA RECOVERY LLC

Provider Business Mailing Address
First Line	:	812 POPLAR ST
Second Line	:
City	:	JOURDANTON
State	:	TX
Zip	:	78026-2940
Country	:	US
Telephone Number	:	830-399-5010
Fax Number	:

Provider Business Practice Location Address
First Line	:	10127 MOROCCO ST STE 196
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-3943
Country	:	US
Telephone Number	:	830-216-6563
Fax Number	:	330-595-4025

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	CHARLES E JUNKIN
Credential	:	MA, LPC/LPCC-S
Telephone Number	:	307-338-0274

Provider Enumeration Date	:	10/19/2023
Last Update Date	:	03/17/2026

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Directions to “VIDA RECOVERY LLC ” Practice Location

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