Provider Demographics
NPI:1710638226
Name:SEAGLASS AZ LLC
Entity Type:Organization
Organization Name:SEAGLASS AZ LLC
Other - Org Name:SEAGLASS RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANDALEE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-562-6271
Mailing Address - Street 1:1590 S CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33406-5957
Mailing Address - Country:US
Mailing Address - Phone:347-693-4239
Mailing Address - Fax:
Practice Address - Street 1:711 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:855-468-3369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-17
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder