MEDICARE: CALDWELL RECOVERY CENTER, 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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1467004580
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALDWELL RECOVERY CENTER, LLC

Provider Business Mailing Address
First Line	:	2719 S KIMBALL AVE
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-5623
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2719 S KIMBALL AVE
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-5623
Country	:	US
Telephone Number	:	208-614-8611
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GAIL VILLARREAL
Credential	:	BS, ICADC
Telephone Number	:	208-614-8611

Provider Enumeration Date	:	07/09/2019
Last Update Date	:	07/09/2019

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