MEDICARE: EAGLECREST 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1922804970
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLECREST RECOVERY LLC

Provider Business Mailing Address
First Line	:	308 N 24TH ST
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72756-3295
Country	:	US
Telephone Number	:	844-439-7627
Fax Number	:	479-367-2899

Provider Business Practice Location Address
First Line	:	308 N 24TH ST
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72756-3295
Country	:	US
Telephone Number	:	844-439-7627
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JOHN HERNANDEZ
Credential	:	LMFT
Telephone Number	:	949-813-5161

Provider Enumeration Date	:	02/20/2025
Last Update Date	:	03/17/2026

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