1063999761 NPI number — LANDMARK RECOVERY OUTPATIENT SERVICES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063999761 NPI number — LANDMARK RECOVERY OUTPATIENT SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LANDMARK RECOVERY OUTPATIENT SERVICES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063999761
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4835 E CACTUS RD STE 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCOTTSDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85254-3545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-551-2163
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4112 FERN VALLEY RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40219-1973
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-221-3932
Provider Business Practice Location Address Fax Number:
502-964-2682
Provider Enumeration Date:
07/25/2018

Additional Information

Authorized Official

Authorized Official Last Name:
LOSOLE
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PRESIDENT, OUTPATIENT SERVICES
Authorized Official Telephone Number:
480-550-2163

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 800286 . This is a "LICENSE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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