Provider Demographics
NPI:1083150296
Name:BRICK HOUSE RECOVERY
Entity Type:Organization
Organization Name:BRICK HOUSE RECOVERY
Other - Org Name:RENAISSANCE RANCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:COOMBS
Authorized Official - Suffix:
Authorized Official - Credentials:MPC
Authorized Official - Phone:801-350-1716
Mailing Address - Street 1:1125 E PINE AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5955
Mailing Address - Country:US
Mailing Address - Phone:208-286-4274
Mailing Address - Fax:
Practice Address - Street 1:1125 E PINE AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5955
Practice Address - Country:US
Practice Address - Phone:208-286-4274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251S00000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251S00000XAgenciesCommunity/Behavioral Health