MEDICARE: MODERN RECOVERY, INC.

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
2	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1649937921
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN RECOVERY, INC.

Provider Business Mailing Address
First Line	:	112 N CENTRAL AVE # 130
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85004-2309
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 N CENTRAL AVE # 130
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85004-2309
Country	:	US
Telephone Number	:	844-991-0555
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF RCM
Name	:	ANDRE BAHBAH
Credential	:
Telephone Number	:	754-270-6654

Provider Enumeration Date	:	11/22/2021
Last Update Date	:	11/22/2021

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Directions to “MODERN RECOVERY, INC. ” Practice Location

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