Provider Demographics
NPI:1265640403
Name:BONDAGE BREAKER RECOVERY SERVICE
Entity Type:Organization
Organization Name:BONDAGE BREAKER RECOVERY SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:DEWAYNE
Authorized Official - Last Name:HEGGIE
Authorized Official - Suffix:
Authorized Official - Credentials:CAS
Authorized Official - Phone:530-529-0634
Mailing Address - Street 1:PO BOX 8652
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-8652
Mailing Address - Country:US
Mailing Address - Phone:530-529-0634
Mailing Address - Fax:530-529-0650
Practice Address - Street 1:224 ASH ST
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-3804
Practice Address - Country:US
Practice Address - Phone:530-529-0634
Practice Address - Fax:530-529-0650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA520003AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility