Basic Information
| Provider Information | |||||||||
| NPI: | 1093973547 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RECOVERY RESOURCES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3950 CHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441144625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164314131 | ||||||||
| FaxNumber: | 2164314151 | ||||||||
| Practice Location | |||||||||
| Address1: | 20525 CENTER RIDGE RD | ||||||||
| Address2: | SUITE 518 | ||||||||
| City: | ROCKY RIVER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441163437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403313838 | ||||||||
| FaxNumber: | 2164314151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2008 | ||||||||
| LastUpdateDate: | 05/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | HEWITT | ||||||||
| AuthorizedOfficialFirstName: | GORDON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2164314131 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 493564 | OH | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0721240 | 05 | OH | MEDICAID | 12772 | 01 | OH | UPIN | OTHER |