Provider Demographics
NPI:1457017642
Name:RECOVERDREAM LLC
Entity Type:Organization
Organization Name:RECOVERDREAM LLC
Other - Org Name:RECOVER/DREAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MARKETING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:662-638-6842
Mailing Address - Street 1:405 GALLERIA DRIVE, SUITE C
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-4717
Mailing Address - Country:US
Mailing Address - Phone:662-638-6842
Mailing Address - Fax:662-638-6842
Practice Address - Street 1:405 GALLERIA DRIVE, SUITE C
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-4717
Practice Address - Country:US
Practice Address - Phone:662-638-6842
Practice Address - Fax:662-638-6842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-11
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder