Provider Demographics
NPI:1629339437
Name:RE-CREATION RETREAT LLC
Entity Type:Organization
Organization Name:RE-CREATION RETREAT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:K
Authorized Official - Last Name:SODERQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:435-691-0856
Mailing Address - Street 1:380 W LOS BARANCOS LN
Mailing Address - Street 2:P.O. BOX 61
Mailing Address - City:KANAB
Mailing Address - State:UT
Mailing Address - Zip Code:84741-3311
Mailing Address - Country:US
Mailing Address - Phone:435-691-0856
Mailing Address - Fax:
Practice Address - Street 1:455 SOUTH MAIN
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:AZ
Practice Address - Zip Code:86022
Practice Address - Country:US
Practice Address - Phone:435-691-0856
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-07
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3895320800000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility