MEDICARE: HORIZON RECOVERY 91ST DR 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	3245S0500X	Children's Substance Abuse Rehabilitation Facility
2	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1508564469
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HORIZON RECOVERY 91ST DR LLC

Provider Business Mailing Address
First Line	:	6635 W HAPPY VALLEY RD STE A104
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85310-2609
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	15921 N 91ST DR
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85382-3585
Country	:	US
Telephone Number	:	623-215-7192
Fax Number	:	623-440-8024

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	BRIAN CARLISLE
Credential	:	FNP-C
Telephone Number	:	623-693-2198

Provider Enumeration Date	:	02/21/2023
Last Update Date	:	06/20/2024

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