Provider Demographics
NPI:1790129401
Name:PRESCOTT ADDICTION RECOVERY CENTER LLC
Entity Type:Organization
Organization Name:PRESCOTT ADDICTION RECOVERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANCE
Authorized Official - Suffix:
Authorized Official - Credentials:DD
Authorized Official - Phone:928-227-2448
Mailing Address - Street 1:1630 SHOUP ST
Mailing Address - Street 2:STE B
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1343
Mailing Address - Country:US
Mailing Address - Phone:928-227-2448
Mailing Address - Fax:928-441-1516
Practice Address - Street 1:1630 SHOUP ST
Practice Address - Street 2:STE B
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1343
Practice Address - Country:US
Practice Address - Phone:928-227-2448
Practice Address - Fax:928-441-1516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-24
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health