Provider Demographics
NPI:1982481594
Name:RECOVERY 369 LLC
Entity Type:Organization
Organization Name:RECOVERY 369 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / RECOVERY COACH
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARDONA
Authorized Official - Suffix:JR
Authorized Official - Credentials:CAPRC II
Authorized Official - Phone:574-369-9664
Mailing Address - Street 1:7411 ASPECT DR UNIT 103
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-7755
Mailing Address - Country:US
Mailing Address - Phone:574-369-9664
Mailing Address - Fax:
Practice Address - Street 1:7411 ASPECT DR UNIT 103
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-7755
Practice Address - Country:US
Practice Address - Phone:574-369-9664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-08
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCAPRC2-5368OtherICAADA