Provider Demographics
NPI:1912365172
Name:ACQUA RECOVERY, LLC
Entity Type:Organization
Organization Name:ACQUA RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-634-4425
Mailing Address - Street 1:1031 S DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-1505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3940 N TRAVERSE MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-4914
Practice Address - Country:US
Practice Address - Phone:954-634-4425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT20785261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder