Provider Demographics
NPI:1053865642
Name:INTERNATIONAL RECOVERY CENTER LLC
Entity Type:Organization
Organization Name:INTERNATIONAL RECOVERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:M
Authorized Official - Last Name:FUNDORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-610-1747
Mailing Address - Street 1:1825 NW 112TH AVE
Mailing Address - Street 2:STE 151
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-1815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1825 NW 112TH AVE
Practice Address - Street 2:STE 151
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-1815
Practice Address - Country:US
Practice Address - Phone:305-610-1747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder