Provider Demographics
NPI:1578330114
Name:JACK RYAN RECOVERY CENTERS
Entity Type:Organization
Organization Name:JACK RYAN RECOVERY CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:520-373-2457
Mailing Address - Street 1:6479 US HIGHWAY 93 S
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-8238
Mailing Address - Country:US
Mailing Address - Phone:520-373-2457
Mailing Address - Fax:
Practice Address - Street 1:825 S DOBSON RD STE 102
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-2901
Practice Address - Country:US
Practice Address - Phone:520-373-2457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty