Provider Demographics
NPI:1013444181
Name:FREEDOM RECOVERY, LLC
Entity Type:Organization
Organization Name:FREEDOM RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:CDP
Authorized Official - Phone:360-960-8595
Mailing Address - Street 1:715 E YELM AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-8714
Mailing Address - Country:US
Mailing Address - Phone:253-961-0116
Mailing Address - Fax:253-960-8594
Practice Address - Street 1:715 E YELM AVE STE 6
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-8714
Practice Address - Country:US
Practice Address - Phone:360-960-8595
Practice Address - Fax:253-960-8594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-18
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA145800261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA145800OtherPRIVATE INSURED