Provider Demographics
NPI:1083790141
Name:ROAD TO RECOVERY
Entity Type:Organization
Organization Name:ROAD TO RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:RICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-503-3764
Mailing Address - Street 1:9304 FOREST LANE
Mailing Address - Street 2:SUITE 269 NORTH
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243
Mailing Address - Country:US
Mailing Address - Phone:214-503-3764
Mailing Address - Fax:214-503-3735
Practice Address - Street 1:9304 FOREST LANE
Practice Address - Street 2:SUITE 269 NORTH
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243
Practice Address - Country:US
Practice Address - Phone:214-503-3764
Practice Address - Fax:214-503-3735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2008-09-02
Deactivation Date:2008-07-29
Deactivation Code:
Reactivation Date:2008-09-02
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0655227Medicaid