Provider Demographics
NPI:1063999761
Name:LANDMARK RECOVERY OUTPATIENT SERVICES LLC
Entity type:Organization
Organization Name:LANDMARK RECOVERY OUTPATIENT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OUTPATIENT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LOSOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-550-2163
Mailing Address - Street 1:4835 E CACTUS RD STE 130
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-3545
Mailing Address - Country:US
Mailing Address - Phone:480-551-2163
Mailing Address - Fax:
Practice Address - Street 1:4112 FERN VALLEY RD STE B
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-1973
Practice Address - Country:US
Practice Address - Phone:502-221-3932
Practice Address - Fax:502-964-2682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-25
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY800286OtherLICENSE