Provider Demographics
NPI:1073984480
Name:A CHANGE INTO RECOVERY, LLC
Entity Type:Organization
Organization Name:A CHANGE INTO RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:BA, CDP, NCAC II
Authorized Official - Phone:253-841-8465
Mailing Address - Street 1:719 E MAIN AVE, SUITE C
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372
Mailing Address - Country:US
Mailing Address - Phone:253-841-8165
Mailing Address - Fax:253-841-8168
Practice Address - Street 1:719 E MAIN AVE, SUITE C
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372
Practice Address - Country:US
Practice Address - Phone:253-841-8165
Practice Address - Fax:253-841-8168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-12
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder