Provider Demographics
NPI:1114549144
Name:PROVIDENCE RECOVERY CENTERS, INC.
Entity Type:Organization
Organization Name:PROVIDENCE RECOVERY CENTERS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:DORSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-221-1805
Mailing Address - Street 1:28728 KALMIA AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555
Mailing Address - Country:US
Mailing Address - Phone:951-221-1805
Mailing Address - Fax:951-422-3384
Practice Address - Street 1:11165 BONNIE VIEW AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555
Practice Address - Country:US
Practice Address - Phone:951-221-1805
Practice Address - Fax:951-422-3384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility