Provider Demographics
NPI:1932643814
Name:MLRC, INC.
Entity Type:Organization
Organization Name:MLRC, INC.
Other - Org Name:MYLIFE RECOVERY CENTERS IOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:FUNKHOUSER
Authorized Official - Suffix:
Authorized Official - Credentials:CATC
Authorized Official - Phone:812-204-4324
Mailing Address - Street 1:6073 N 1ST ST STE 102
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5444
Mailing Address - Country:US
Mailing Address - Phone:559-202-3830
Mailing Address - Fax:
Practice Address - Street 1:6073 N 1ST ST STE 102
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5444
Practice Address - Country:US
Practice Address - Phone:559-202-3830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder