Basic Information
| Provider Information | |||||||||
| NPI: | 1962831461 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RECOVERY RESOURCES | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4269 PEARL RD | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441094234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164314131 | ||||||||
| FaxNumber: | 2164314151 | ||||||||
| Practice Location | |||||||||
| Address1: | 4269 PEARL RD | ||||||||
| Address2: | |||||||||
| City: | EAST CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441122806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164314131 | ||||||||
| FaxNumber: | 2164314151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2013 | ||||||||
| LastUpdateDate: | 08/20/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VON ALT | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2164314131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 01-0435 | OH | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 2408793 | 05 | OH | MEDICAID | 2863736 | 05 | OH | MEDICAID |