Provider Demographics
NPI:1316225444
Name:ROUND TABLE RECOVERY, LLC
Entity Type:Organization
Organization Name:ROUND TABLE RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:IRA
Authorized Official - Middle Name:N
Authorized Official - Last Name:NISHIKAWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-533-2887
Mailing Address - Street 1:711 S GRANITE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-4241
Mailing Address - Country:US
Mailing Address - Phone:928-533-2887
Mailing Address - Fax:928-776-4781
Practice Address - Street 1:711 S GRANITE ST
Practice Address - Street 2:SUITE B
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-4241
Practice Address - Country:US
Practice Address - Phone:928-533-2887
Practice Address - Fax:928-776-4781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-22
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health