Provider Demographics
NPI:1932595899
Name:ACQUA RECOVERY LLC
Entity Type:Organization
Organization Name:ACQUA RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-678-0078
Mailing Address - Street 1:1031 S DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-1505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 N JOHNSON MILL RD
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:UT
Practice Address - Zip Code:84049-6764
Practice Address - Country:US
Practice Address - Phone:954-678-0078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13415261QR0405X
UT13414261QR0405X
UT10218324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility