Provider Demographics
NPI:1629801543
Name:CHRONICLES OF SUCCESS RECOVERY SERVICES LLC
Entity type:Organization
Organization Name:CHRONICLES OF SUCCESS RECOVERY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DONIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOAZEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-977-2767
Mailing Address - Street 1:5441 S MACADAM AVE STE N
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-6106
Mailing Address - Country:US
Mailing Address - Phone:866-674-3347
Mailing Address - Fax:
Practice Address - Street 1:3140 JUANIPERO WAY STE 101
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8647
Practice Address - Country:US
Practice Address - Phone:541-508-0336
Practice Address - Fax:541-508-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-26
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No174200000XOther Service ProvidersMeals
No177F00000XOther Service ProvidersLodging
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder