Provider Demographics
NPI:1871038067
Name:AVISTA RECOVERY
Entity Type:Organization
Organization Name:AVISTA RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:LICARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-815-7737
Mailing Address - Street 1:12359 WOLF RUN RD
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-7232
Mailing Address - Country:US
Mailing Address - Phone:630-815-7737
Mailing Address - Fax:
Practice Address - Street 1:12359 WOLF RUN RD
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-7232
Practice Address - Country:US
Practice Address - Phone:630-815-7737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-27
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility