Provider Demographics
NPI:1790503829
Name:PHOENIX RECOVERY CLINIC LLC
Entity type:Organization
Organization Name:PHOENIX RECOVERY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:MUNOZ RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-200-0222
Mailing Address - Street 1:842 S 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-3910
Mailing Address - Country:US
Mailing Address - Phone:480-200-0222
Mailing Address - Fax:
Practice Address - Street 1:842 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-3910
Practice Address - Country:US
Practice Address - Phone:480-200-0222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities