Provider Demographics
NPI:1558132704
Name:NORTHSIGHT RECOVERY LLC
Entity Type:Organization
Organization Name:NORTHSIGHT RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-544-0283
Mailing Address - Street 1:1440 E SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:605 N GILBERT RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-6629
Practice Address - Country:US
Practice Address - Phone:480-544-0283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-15
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No291U00000XLaboratoriesClinical Medical Laboratory
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
03D2289209OtherCLIA
AZ185032Medicaid
AZOTC13229OtherDEPARTMENT OF HEALTH LICENSE