Provider Demographics
NPI:1598235665
Name:PHOENIX ADDICTION RECOVERY LLC
Entity Type:Organization
Organization Name:PHOENIX ADDICTION RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTHIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-501-8097
Mailing Address - Street 1:1839 E MALLORY ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-1329
Mailing Address - Country:US
Mailing Address - Phone:602-501-8097
Mailing Address - Fax:
Practice Address - Street 1:4135 S POWER RD STE 113
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-3625
Practice Address - Country:US
Practice Address - Phone:602-501-8097
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder