Provider Demographics
NPI:1013460385
Name:PRESCOTT ADDICTION RECOVERY CENTER LLC
Entity Type:Organization
Organization Name:PRESCOTT ADDICTION RECOVERY CENTER LLC
Other - Org Name:PARC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANCE
Authorized Official - Suffix:
Authorized Official - Credentials:D DIV
Authorized Official - Phone:928-227-2448
Mailing Address - Street 1:1630 SHOUP ST
Mailing Address - Street 2:SUITE 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:
Practice Address - Street 1:1630 SHOUP ST
Practice Address - Street 2:SUITE 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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC7711251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health