Provider Demographics
NPI:1447712120
Name:AWAKENING RECOVERY CENTER
Entity type:Organization
Organization Name:AWAKENING RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:LISAC
Authorized Official - Phone:480-209-1977
Mailing Address - Street 1:1204 E BASELINE RD STE 208
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1453
Mailing Address - Country:US
Mailing Address - Phone:480-209-1977
Mailing Address - Fax:480-404-9716
Practice Address - Street 1:293 W 5TH ST
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-2324
Practice Address - Country:US
Practice Address - Phone:928-428-8070
Practice Address - Fax:480-404-9716
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AWAKENING RECOVERY CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-02
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ237605Medicaid