Provider Demographics
NPI:1417458753
Name:REBOOT DETOX AZ LLC
Entity Type:Organization
Organization Name:REBOOT DETOX AZ LLC
Other - Org Name:FOOTPRINTS TO RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:YESHAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARKOVITS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-868-1600
Mailing Address - Street 1:PO BOX 1030
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-0090
Mailing Address - Country:US
Mailing Address - Phone:732-903-1964
Mailing Address - Fax:
Practice Address - Street 1:1132 S OAKLAND
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2682
Practice Address - Country:US
Practice Address - Phone:732-903-1964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZIFBH8704324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility