1447005202 NPI number — RECOVERY ACADEMY, LLC

Table of content: (NPI 1447005202)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447005202 NPI number — RECOVERY ACADEMY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RECOVERY ACADEMY, 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:
1447005202
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1295 NORTHLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENDOTA HEIGHTS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55120-1371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-900-7021
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
828 SUMMIT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55105-3354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
339-300-4549
Provider Business Practice Location Address Fax Number:
651-305-0708
Provider Enumeration Date:
04/23/2024

Additional Information

Authorized Official

Authorized Official Last Name:
UTRZAN
Authorized Official First Name:
DAMIR
Authorized Official Middle Name:
STEVAN
Authorized Official Title or Position:
PRESIDENT AND CEO
Authorized Official Telephone Number:
612-900-7021

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1122623 . This is a "DEPARTMENT OF HUMAN SERVICES" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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