Provider Demographics
NPI:1114168564
Name:SPIRIT LAKE RECOVERY, LLC
Entity Type:Organization
Organization Name:SPIRIT LAKE RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMROK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-431-3010
Mailing Address - Street 1:1060 OLD MCKENZIE RD
Mailing Address - Street 2:
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-8667
Mailing Address - Country:US
Mailing Address - Phone:731-393-0304
Mailing Address - Fax:
Practice Address - Street 1:1060 OLD MCKENZIE RD
Practice Address - Street 2:
Practice Address - City:MC KENZIE
Practice Address - State:TN
Practice Address - Zip Code:38201-8667
Practice Address - Country:US
Practice Address - Phone:731-393-0304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4072324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility