Provider Demographics
NPI:1174252985
Name:EAGLECREST RECOVERY LLC
Entity Type:Organization
Organization Name:EAGLECREST RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:949-813-5161
Mailing Address - Street 1:PO BOX 1728
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-1728
Mailing Address - Country:US
Mailing Address - Phone:760-521-2653
Mailing Address - Fax:
Practice Address - Street 1:19965 LAKEVIEW RD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-8892
Practice Address - Country:US
Practice Address - Phone:949-813-5161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility