Provider Demographics
NPI:1366035594
Name:BETTY LOU WALLACE RECOVERY LLC
Entity Type:Organization
Organization Name:BETTY LOU WALLACE RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GEFFEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LIBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-388-1495
Mailing Address - Street 1:13340 HOLMES RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64145-1437
Mailing Address - Country:US
Mailing Address - Phone:816-786-7074
Mailing Address - Fax:
Practice Address - Street 1:13643 HOLMES RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64145-1482
Practice Address - Country:US
Practice Address - Phone:480-388-1495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility