Provider Demographics
NPI:1871987495
Name:EMBARK RECOVERY LLC
Entity type:Organization
Organization Name:EMBARK RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:H
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-445-0778
Mailing Address - Street 1:3727 KARICIO LN
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-6829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3727 KARICIO LN
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-6829
Practice Address - Country:US
Practice Address - Phone:928-445-0778
Practice Address - Fax:928-445-0780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-20
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC 7091261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ520332Medicaid