Provider Demographics
NPI:1679039044
Name:SEAGLASS RECOVERY
Entity Type:Organization
Organization Name:SEAGLASS RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF QUALITY ASSURANCE
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-379-3097
Mailing Address - Street 1:701 S SWINTON AVE APT G
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33444-2377
Mailing Address - Country:US
Mailing Address - Phone:877-732-6837
Mailing Address - Fax:
Practice Address - Street 1:707 W GURLEY ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-3621
Practice Address - Country:US
Practice Address - Phone:877-732-6837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH5497OtherARIZONA DEPARTMENT OF HEALTH SERVICES LICENSE NUMBER