Provider Demographics
NPI:1437307774
Name:RECOVERY EMPOWERMENT NETWORK, INC.
Entity Type:Organization
Organization Name:RECOVERY EMPOWERMENT NETWORK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE & CREDENTIALING COOR
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:ELISA
Authorized Official - Last Name:ANTTILAINEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-248-0368
Mailing Address - Street 1:212 E. OSBORN RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012
Mailing Address - Country:US
Mailing Address - Phone:602-248-0368
Mailing Address - Fax:602-279-2806
Practice Address - Street 1:212 E. OSBORN RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012
Practice Address - Country:US
Practice Address - Phone:602-248-0368
Practice Address - Fax:602-279-2806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-28
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCSA08ADHS0187251S00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ073523Medicaid